Provider Demographics
NPI:1689014599
Name:BLICK, KEVIN MICHAEL (AA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:BLICK
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 MARMOT LN
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-9492
Mailing Address - Country:US
Mailing Address - Phone:303-324-7867
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000013367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant