Provider Demographics
NPI:1427299353
Name:MANN, KEVIN (RPA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MANN
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1932
Mailing Address - Country:US
Mailing Address - Phone:917-514-4411
Mailing Address - Fax:
Practice Address - Street 1:1305 OAK AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1932
Practice Address - Country:US
Practice Address - Phone:917-514-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013031363A00000X
CAPA21311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant