Provider Demographics
NPI:1629014907
Name:WARD, KEVIN R (CRNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:WARD
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CLARK-HOLDER CLINIC, P.A.
Mailing Address - Street 2:303 SMITH STREET
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-882-8831
Mailing Address - Fax:706-812-4091
Practice Address - Street 1:CLARK-HOLDER CLINIC, P.A.
Practice Address - Street 2:303 SMITH STREET
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-882-8831
Practice Address - Fax:706-812-4091
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA147488363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P32002Medicare UPIN
GA50BBFFGMedicare ID - Type Unspecified