Provider Demographics
NPI:1730496977
Name:BETTENCOURT, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BETTENCOURT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:5901 HARPER DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3589
Practice Address - Country:US
Practice Address - Phone:505-823-8233
Practice Address - Fax:505-823-8059
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIPA00611363A00000X
FLPAT9105615363A00000X
NMPA2011-0012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant