Provider Demographics
NPI:1295378610
Name:HINDMAN, KODY ALAN
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:ALAN
Last Name:HINDMAN
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 1:670 PIERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2579
Mailing Address - Country:US
Mailing Address - Phone:618-206-2094
Mailing Address - Fax:618-607-5127
Practice Address - Street 1:670 PIERCE BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2579
Practice Address - Country:US
Practice Address - Phone:618-206-2094
Practice Address - Fax:618-607-5127
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007288363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant