Provider Demographics
NPI:1588853675
Name:WANSOR, KEVIN JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOHN
Last Name:WANSOR
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:30 MEDICAL CENTER BLVD SUITE 303
Mailing Address - Street 2:CLINICAL RENAL ASSOCIATES LTD
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013-3995
Mailing Address - Country:US
Mailing Address - Phone:610-872-8501
Mailing Address - Fax:610-872-5188
Practice Address - Street 1:30 MEDICAL CENTER BLVD SUITE 303
Practice Address - Street 2:CLINICAL RENAL ASSOCIATES LTD
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013-3995
Practice Address - Country:US
Practice Address - Phone:610-872-8501
Practice Address - Fax:610-872-5188
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2013-12-20
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Provider Licenses
StateLicense IDTaxonomies
PAMA053066363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
117574FHJMedicare PIN