Healthcare Provider Details

I. General information

NPI: 1295955441
Provider Name (Legal Business Name): KEVIN CLARK ROBERTSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EUCALYPTUS DR
EL SEGUNDO CA
90245-3839
US

IV. Provider business mailing address

444 S SAN VICENTE BLVD SUITE 800
LOS ANGELES CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 310-322-4278
  • Fax: 310-322-6660
Mailing address:
  • Phone: 310-423-9716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: