Provider Demographics
NPI:1164790721
Name:SKINNER, KEVIN (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SKINNER
Suffix:
Gender:M
Credentials:PA
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-606-6400
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA07717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-0818167-048OtherTRICARE
TX75-1976930-005OtherTRICARE
TX75-2616977-028OtherTRICARE
TXP01200590OtherRAIL ROAD
TXP01276462OtherRAIL ROAD
TX288707706Medicaid
TX288707707Medicaid
TXP01200614OtherRAIL ROAD
TX288707704Medicaid
TX288707703Medicaid
TX8107NDOtherBCBS
TX8108NDOtherBCBS
TX75-0818167-015OtherTRICARE
TX75-0818167-044OtherTRICARE
TX75-2616977-001OtherTRICARE
TX75-2616977-129OtherTRICARE
TX288707705Medicaid
TX75-0818167-022OtherTRICARE
TX75-2616977-002OtherTRICARE
TX8808NAOtherBCBS
TXP01200614OtherRAIL ROAD
TX8108NDOtherBCBS
TX75-2616977-001OtherTRICARE
TX288707704Medicaid