Provider Demographics
NPI:1043645617
Name:WARREN, KEVIN M
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:WARREN
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 1:1520 S DOBSON RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4725
Mailing Address - Country:US
Mailing Address - Phone:480-412-4839
Mailing Address - Fax:
Practice Address - Street 1:1520 S DOBSON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4725
Practice Address - Country:US
Practice Address - Phone:480-412-4839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5450363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical