Provider Demographics
NPI:1922238195
Name:FATKIN, KENNETH ERVINE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ERVINE
Last Name:FATKIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 W WARM SPRINGS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-7632
Mailing Address - Country:US
Mailing Address - Phone:702-435-7987
Mailing Address - Fax:702-435-7616
Practice Address - Street 1:1485 W WARM SPRINGS RD STE 102
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-7632
Practice Address - Country:US
Practice Address - Phone:702-435-7987
Practice Address - Fax:702-435-7616
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1008213EP1101X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVEG370ZMedicare UPIN