Provider Demographics
NPI:1952664799
Name:FREE, KEVIN RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:FREE
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 1:3930 WALNUT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4750
Mailing Address - Country:US
Mailing Address - Phone:703-246-9246
Mailing Address - Fax:703-246-9257
Practice Address - Street 1:3930 WALNUT ST STE 101
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4750
Practice Address - Country:US
Practice Address - Phone:703-246-9246
Practice Address - Fax:703-246-9257
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04779363AM0700X
VA0110009144363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical