Provider Demographics
NPI:1740804665
Name:BARNWELL, KEVIN JACOB (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JACOB
Last Name:BARNWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9750 OLD PLACERVILLE RD APT 168
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-3356
Mailing Address - Country:US
Mailing Address - Phone:480-332-4775
Mailing Address - Fax:
Practice Address - Street 1:1420 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3451
Practice Address - Country:US
Practice Address - Phone:209-832-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA58643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant