Provider Demographics
NPI:1588803928
Name:MIXON, KEVIN O (NP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:O
Last Name:MIXON
Suffix:
Gender:M
Credentials:NP
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 3087
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-3087
Mailing Address - Country:US
Mailing Address - Phone:985-230-7495
Mailing Address - Fax:985-230-1861
Practice Address - Street 1:15770 PAUL VEGA MD DR STE 202
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1475
Practice Address - Country:US
Practice Address - Phone:985-230-7495
Practice Address - Fax:985-230-7496
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03979363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP01359174OtherMEDICARE RR
LA2142348Medicaid
LAP01359174OtherMEDICARE RR