Provider Demographics
NPI:1033804240
Name:PHYSIOC, KEVIN ANDREW
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:PHYSIOC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17287 HARPER LN
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9624
Mailing Address - Country:US
Mailing Address - Phone:949-300-9838
Mailing Address - Fax:
Practice Address - Street 1:760 S AUBURN ST STE C2
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4318
Practice Address - Country:US
Practice Address - Phone:530-265-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker