Provider Demographics
NPI:1336283803
Name:SMALLWOOD, KEVIN WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLIAM
Last Name:SMALLWOOD
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 1:4755 OGLETOWN-STANTON RD, SUITE 1E50
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718
Mailing Address - Country:US
Mailing Address - Phone:302-733-1980
Mailing Address - Fax:302-733-1986
Practice Address - Street 1:4755 OGLETOWN-STANTON DR
Practice Address - Street 2:SUITE 1E50
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718
Practice Address - Country:US
Practice Address - Phone:302-733-1980
Practice Address - Fax:302-733-1986
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001161363AS0400X, 363A00000X
DECS-0000589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE003705C91Medicare PIN