Provider Demographics
NPI:1811583263
Name:EITEL, KEVIN RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:EITEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1669 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5216
Mailing Address - Country:US
Mailing Address - Phone:650-888-6733
Mailing Address - Fax:
Practice Address - Street 1:325 SHARON PARK DR STE F3
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-6848
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58942207P00000X
CA58942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine