Provider Demographics
NPI:1669430336
Name:MCGILLICUDDY, KEVIN G (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:MCGILLICUDDY
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 1:800 MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2304
Mailing Address - Country:US
Mailing Address - Phone:561-955-7100
Mailing Address - Fax:
Practice Address - Street 1:800 MEADOWS RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2304
Practice Address - Country:US
Practice Address - Phone:561-955-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2913363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS90033Medicare UPIN
FLE3120Medicare ID - Type Unspecified