Provider Demographics
NPI:1497916795
Name:MARRA, KEVIN YORK (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:YORK
Last Name:MARRA
Suffix:
Gender:M
Credentials:MD
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 60724
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0724
Mailing Address - Country:US
Mailing Address - Phone:704-358-2700
Mailing Address - Fax:704-358-2716
Practice Address - Street 1:501 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-358-2700
Practice Address - Fax:704-358-2716
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC149310390200000X
NC2010-014782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1497916795Medicaid
SCNC1897Medicaid
NCNCF877AMedicare PIN