Provider Demographics
NPI:1760534861
Name:KEVAN, JONATHAN R (MD)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:R
Last Name:KEVAN
Suffix:
Gender:M
Credentials:MD
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 26028
Mailing Address - Street 2:CREDENTIALING/ CLINICIAN SERVICES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-237-8700
Mailing Address - Fax:505-237-8703
Practice Address - Street 1:2111 LOBO CANYON RD
Practice Address - Street 2:WNMCF
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020
Practice Address - Country:US
Practice Address - Phone:505-876-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0623207Q00000X
IDM-9759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1055258317OtherAMERICAN BOARD OF FAMILY MEDICINE CERTIFICATION