Provider Demographics
NPI:1942296637
Name:SWANSON, KEVIN L (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:SWANSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 DEXTER CT
Mailing Address - Street 2:STE 301
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3471
Mailing Address - Country:US
Mailing Address - Phone:563-344-6645
Mailing Address - Fax:563-441-7796
Practice Address - Street 1:3385 DEXTER CT
Practice Address - Street 2:STE 301
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-344-6645
Practice Address - Fax:563-441-7796
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01358225100000X
IL070006210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA213140008Medicare PIN
S83223Medicare UPIN