Provider Demographics
NPI:1497787345
Name:CONWAY, KEVIN M (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:CONWAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521-525 COLLEGE AVENUE SUITE 111
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4131
Mailing Address - Country:US
Mailing Address - Phone:707-568-0111
Mailing Address - Fax:707-568-6805
Practice Address - Street 1:521-525 COLLEGE AVE.
Practice Address - Street 2:111
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4131
Practice Address - Country:US
Practice Address - Phone:707-568-0111
Practice Address - Fax:707-568-6805
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9560225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT95600Medicare PIN