MEDICARE: KEVIN L HENRY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5177317-1206	UT
2	363A00000X	Physician Assistant	0110004898	VA

General Provider Information

NPI Number	:	1750370508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN L HENRY PA-C

Provider Business Mailing Address
First Line	:	1635 N GEORGE MASON DR
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205-3601
Country	:	US
Telephone Number	:	703-522-5300
Fax Number	:	703-908-0148

Provider Business Practice Location Address
First Line	:	1635 N GEORGE MASON DR
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22205-3601
Country	:	US
Telephone Number	:	703-522-5300
Fax Number	:	703-908-0148

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	12/14/2016

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