Provider Demographics
NPI:1457100166
Name:PAULK, KEVIN ANDREW (PTA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ANDREW
Last Name:PAULK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3389 208TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-2323
Mailing Address - Country:US
Mailing Address - Phone:386-697-8200
Mailing Address - Fax:
Practice Address - Street 1:7207 SW 24TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-3706
Practice Address - Country:US
Practice Address - Phone:352-333-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27983225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant