Provider Demographics
NPI:1598744021
Name:TRAHAN, KEVIN (IDMT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TRAHAN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 OCEAN ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-2416
Mailing Address - Country:US
Mailing Address - Phone:904-564-7581
Mailing Address - Fax:904-564-7583
Practice Address - Street 1:4200 OCEAN ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-2416
Practice Address - Country:US
Practice Address - Phone:904-564-7581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Not Answered1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1710I1003XOtherIDMT