Provider Demographics
NPI:1306405931
Name:PATRICK, KEVIN RYAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:PATRICK
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 SCHINDLER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-0540
Mailing Address - Country:US
Mailing Address - Phone:585-224-5680
Mailing Address - Fax:
Practice Address - Street 1:87TH MEDICAL GROUP
Practice Address - Street 2:3458 NEELY RD
Practice Address - City:MCGUIRE AFB
Practice Address - State:NJ
Practice Address - Zip Code:08641
Practice Address - Country:US
Practice Address - Phone:866-377-2778
Practice Address - Fax:609-754-9223
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00794900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program