Provider Demographics
NPI:1013997881
Name:SKINNER, KEVIN (MD, DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SKINNER
Suffix:
Gender:M
Credentials:MD, DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2963 E ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-9426
Mailing Address - Country:US
Mailing Address - Phone:480-399-4577
Mailing Address - Fax:
Practice Address - Street 1:2963 E ROBIN LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-9426
Practice Address - Country:US
Practice Address - Phone:480-399-4577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17122207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ286824Medicaid
NV1013997881Medicaid
NV1013997881Medicaid
AZ286824Medicaid