Provider Demographics
NPI:1942205430
Name:GIACONTIERE, KEVIN JOSEPH (PA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:GIACONTIERE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 JEFFERSON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6224
Mailing Address - Country:US
Mailing Address - Phone:512-451-0139
Mailing Address - Fax:512-323-5880
Practice Address - Street 1:3500 JEFFERSON ST
Practice Address - Street 2:STE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6224
Practice Address - Country:US
Practice Address - Phone:512-451-0139
Practice Address - Fax:512-323-5880
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01948363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0040EEOtherBLUE CROSS BLUE SHIELD
TX88N360OtherBLUE CROSS BLUE SHIELD
TX970030195OtherMEDICARE RAILROAD
TXCK7292OtherMEDICARE RAILROAD
TX0040EEOtherBLUE CROSS BLUE SHIELD
TX88N360OtherBLUE CROSS BLUE SHIELD