Provider Demographics
NPI:1831511856
Name:LITTLE, KEVIN THOMAS (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:THOMAS
Last Name:LITTLE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-2712
Mailing Address - Country:US
Mailing Address - Phone:925-708-9328
Mailing Address - Fax:
Practice Address - Street 1:1466 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2021
Practice Address - Country:US
Practice Address - Phone:925-708-9328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA546706163W00000X
CA11746363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse