Provider Demographics
NPI:1407056013
Name:FERGUSON, KEVIN JOHN (NP-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-6743
Mailing Address - Country:US
Mailing Address - Phone:269-639-5271
Mailing Address - Fax:
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6743
Practice Address - Country:US
Practice Address - Phone:269-639-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704218229363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407056013OtherNPI
MI1407056013OtherNPI
MI4416Medicare PIN