Provider Demographics
NPI:1528194867
Name:CLEMONS, KEVIN LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20868-0599
Mailing Address - Country:US
Mailing Address - Phone:240-786-5804
Mailing Address - Fax:949-862-5121
Practice Address - Street 1:234 W NORTHFIELD BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-1590
Practice Address - Country:US
Practice Address - Phone:615-895-6995
Practice Address - Fax:615-895-6994
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant