Provider Demographics
NPI:1265453336
Name:NEWCOM, KEVIN DALE (APN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DALE
Last Name:NEWCOM
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 HIGHWAY 5 N
Mailing Address - Street 2:
Mailing Address - City:ROMANCE
Mailing Address - State:AR
Mailing Address - Zip Code:72136-9618
Mailing Address - Country:US
Mailing Address - Phone:501-257-2705
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:501-257-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily