Provider Demographics
NPI:1750927562
Name:PFAFF, KEVIN TIMOTHY (RN)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:TIMOTHY
Last Name:PFAFF
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 W STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3117
Mailing Address - Country:US
Mailing Address - Phone:408-916-7500
Mailing Address - Fax:
Practice Address - Street 1:2150 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1337
Practice Address - Country:US
Practice Address - Phone:916-875-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95113573163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse