Provider Demographics
NPI:1558315135
Name:HINES, KEVIN THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:HINES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2443
Mailing Address - Country:US
Mailing Address - Phone:360-385-5444
Mailing Address - Fax:360-385-5352
Practice Address - Street 1:1010 SHERIDAN ST STE 201
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2901
Practice Address - Country:US
Practice Address - Phone:360-385-5444
Practice Address - Fax:360-385-5352
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8420135Medicaid
WA4719830002Medicare NSC
WA8853306Medicare ID - Type Unspecified
WA8420135Medicaid