Provider Demographics
NPI:1588852503
Name:CARDWELL, KEVIN W (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:CARDWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642302
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164-2302
Mailing Address - Country:US
Mailing Address - Phone:509-335-3575
Mailing Address - Fax:509-335-6223
Practice Address - Street 1:1125 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-2484
Practice Address - Country:US
Practice Address - Phone:509-335-3575
Practice Address - Fax:509-335-6223
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10005304363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1057194Medicaid