Provider Demographics
NPI:1275672503
Name:TIYAAMORNWONG, KEVIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:TIYAAMORNWONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-3631
Mailing Address - Country:US
Mailing Address - Phone:559-664-4000
Mailing Address - Fax:559-675-5224
Practice Address - Street 1:344 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-3631
Practice Address - Country:US
Practice Address - Phone:559-664-4000
Practice Address - Fax:559-675-5224
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 14398OtherLICENSE
CAPA 14398OtherLICENSE
CAMT1309574OtherDEA