Provider Demographics
NPI:1295955441
Name:ROBERTSON, KEVIN CLARK (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CLARK
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 S SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:310-423-9716
Mailing Address - Fax:
Practice Address - Street 1:125 EUCALYPTUS DR
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3839
Practice Address - Country:US
Practice Address - Phone:310-322-4278
Practice Address - Fax:310-322-6660
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17110OtherMEDICAL LICENSE