Healthcare Provider Details

I. General information

NPI: 1285293969
Provider Name (Legal Business Name): KEVIN TATUM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MALL DR
HANFORD CA
93230-5786
US

IV. Provider business mailing address

6673 E CORNELL AVE
FRESNO CA
93727-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-582-9000
  • Fax:
Mailing address:
  • Phone: 559-577-7872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95045187
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: