Provider Demographics
NPI:1780687376
Name:WASKIN, KEVIN D (PAC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:D
Last Name:WASKIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8591 CROSSROADS DRIVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514
Mailing Address - Country:US
Mailing Address - Phone:330-758-0577
Mailing Address - Fax:330-758-0466
Practice Address - Street 1:8591 CROSSROADS DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514
Practice Address - Country:US
Practice Address - Phone:330-758-0577
Practice Address - Fax:330-758-0466
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002133363A00000X
OH50-00-2133363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341972661OtherTAX ID
OH341972661OtherTAX ID
OH50-00-2133OtherLICENSE
PAMA001738-LOtherLICENSE
OH341972661OtherTAX ID
OHS28587Medicare UPIN