Provider Demographics
NPI:1164425633
Name:REDUS, KEVIN LAMAR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LAMAR
Last Name:REDUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3811 E BELL RD STE 309
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2160
Mailing Address - Country:US
Mailing Address - Phone:480-420-0749
Mailing Address - Fax:480-420-0732
Practice Address - Street 1:520 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1447
Practice Address - Country:US
Practice Address - Phone:928-684-5421
Practice Address - Fax:289-684-7457
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2477363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0146700OtherBLUE CROSS BLUE SHIELD AZ
AZ577786001Medicaid
AZ577786Medicaid
AZ577786001Medicaid