Provider Demographics
NPI:1205130853
Name:MAINZ, KEVIN G (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:MAINZ
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 1:8230 WALNUT HILL LN STE 220
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4425
Mailing Address - Country:US
Mailing Address - Phone:214-345-8692
Mailing Address - Fax:
Practice Address - Street 1:8230 WALNUT HILL LN STE 220
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4425
Practice Address - Country:US
Practice Address - Phone:214-345-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
TXPA07099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB142426Medicare PIN
TXTXB142427Medicare PIN
TXTXB142428Medicare PIN