Provider Demographics
NPI:1649370776
Name:FREEMAN, KEVIN WAYNE (CRNFA, RNFA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WAYNE
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:CRNFA, RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42123
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-2123
Mailing Address - Country:US
Mailing Address - Phone:520-318-6039
Mailing Address - Fax:520-320-0081
Practice Address - Street 1:4500 E SPEEDWAY BLVD
Practice Address - Street 2:SUITE 60
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-5303
Practice Address - Country:US
Practice Address - Phone:520-318-6039
Practice Address - Fax:520-320-0081
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN098085163WM0705X
AZ985962174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554403 01Medicaid