Healthcare Provider Details

I. General information

NPI: 1770143547
Provider Name (Legal Business Name): KEVIN KIRK ANDERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF THE AIR FORCE 86 MDG OPC 02 BOX 60
APO AE
09094 9001
DE

IV. Provider business mailing address

DEPARTMENT OF THE AIR FORCE 86 MDG OPC 02 BOX 60
APO AE
09094 9001
DE

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013999
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT013999
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: