Provider Demographics
NPI:1376919456
Name:LI, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LI
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 1:7500 HANOVER PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2011
Mailing Address - Country:US
Mailing Address - Phone:301-220-2220
Mailing Address - Fax:301-220-2224
Practice Address - Street 1:7500 HANOVER PKWY STE 105
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2011
Practice Address - Country:US
Practice Address - Phone:301-220-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005753363AM0700X
CA52689363AM0700X
MDC0006528363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical