Provider Demographics
NPI:1205542982
Name:POWELL, KEMOY SHAVAR (PA-C)
Entity type:Individual
Prefix:
First Name:KEMOY
Middle Name:SHAVAR
Last Name:POWELL
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 1:1387 NORMAN ST APT B
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-1821
Mailing Address - Country:US
Mailing Address - Phone:203-224-0965
Mailing Address - Fax:
Practice Address - Street 1:1387 NORMAN ST APT B
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-1821
Practice Address - Country:US
Practice Address - Phone:203-224-0965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant