Provider Demographics
NPI:1477116952
Name:ALLISON, KEVIN GARRETT (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:GARRETT
Last Name:ALLISON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13330 USF LAUREL DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6601
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN2T30OtherBLUE CROSS BLUE SHIELD
FL103408800Medicaid