Provider Demographics
NPI:1235839937
Name:ANDERSON, KEVIN C
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:ANDERSON
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 1:243 COUNTRY CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-6238
Mailing Address - Country:US
Mailing Address - Phone:757-897-8938
Mailing Address - Fax:
Practice Address - Street 1:1800 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2386
Practice Address - Country:US
Practice Address - Phone:703-383-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program