Provider Demographics
NPI:1558396465
Name:PRINCE, KEVIN M (FNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:PRINCE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 GULF FWY S
Mailing Address - Street 2:STE 230
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5100
Mailing Address - Country:US
Mailing Address - Phone:281-557-4404
Mailing Address - Fax:281-557-4443
Practice Address - Street 1:538 BROADWAY
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665-7600
Practice Address - Country:US
Practice Address - Phone:409-296-6000
Practice Address - Fax:409-296-6375
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP113090363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N7097OtherBCBS
TX168116503Medicaid
TX8B9696Medicare PIN
TXQ15101Medicare UPIN