Provider Demographics
NPI:1720688443
Name:MARSTON, KEVIN JAMES (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:MARSTON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13555 W MCDOWELL RD
Mailing Address - Street 2:STE 205
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2626
Mailing Address - Country:US
Mailing Address - Phone:207-831-2002
Mailing Address - Fax:
Practice Address - Street 1:6602 E PHELPS RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5659
Practice Address - Country:US
Practice Address - Phone:207-831-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ249498363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1720688443Medicaid