Provider Demographics
NPI:1740663608
Name:MITCHAM, KEVIN MICAEL (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICAEL
Last Name:MITCHAM
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE STE L119
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-1239
Practice Address - Country:US
Practice Address - Phone:859-257-3253
Practice Address - Fax:859-323-1203
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC110363AS0400X, 363A00000X, 363AM0700X
TN2796363AS0400X, 363A00000X, 363AM0700X
IN10003888A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233690173OtherMEDICARE
IN300070423Medicaid