Provider Demographics
NPI:1932812237
Name:DIMAURO, KEVIN ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
Last Name:DIMAURO
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 1:901 ENTERPRISE PKWY STE 900
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6250
Mailing Address - Country:US
Mailing Address - Phone:757-827-2480
Mailing Address - Fax:757-827-2566
Practice Address - Street 1:901 ENTERPRISE PKWY STE 900
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6250
Practice Address - Country:US
Practice Address - Phone:757-827-2480
Practice Address - Fax:757-827-2566
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017645790001Medicaid
VA0110009350OtherVIRGINIA PHYSICIAN ASSISTANT LICENSE