Provider Demographics
NPI:1508809617
Name:MOUNCE, KEVIN GENE (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:GENE
Last Name:MOUNCE
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 1:1 SISKIN PLZ
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-1306
Mailing Address - Country:US
Mailing Address - Phone:423-634-4226
Mailing Address - Fax:423-634-4222
Practice Address - Street 1:1 SISKIN PLZ
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1306
Practice Address - Country:US
Practice Address - Phone:423-634-4226
Practice Address - Fax:423-634-4222
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000053363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3662060Medicaid
TN4131998OtherBCBSTN
TN4131998OtherBCBSTN
TN3662060Medicare PIN
P36460Medicare UPIN
GA97WCHZTMedicare PIN