Provider Demographics
NPI:1750370508
Name:HENRY, KEVIN L (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:HENRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 N GEORGE MASON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3601
Mailing Address - Country:US
Mailing Address - Phone:703-522-5300
Mailing Address - Fax:703-908-0148
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3601
Practice Address - Country:US
Practice Address - Phone:703-522-5300
Practice Address - Fax:703-908-0148
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5177317-1206363A00000X
VA0110004898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS33304Medicare UPIN