Healthcare Provider Details

I. General information

NPI: 1376919456
Provider Name (Legal Business Name): KEVIN XINGYU LI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6707 DEMOCRACY BLVD STE 504
BETHESDA MD
20817-1166
US

IV. Provider business mailing address

6707 DEMOCRACY BLVD STE 504
BETHESDA MD
20817-1166
US

V. Phone/Fax

Practice location:
  • Phone: 301-637-8712
  • Fax: 301-547-3366
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110005753
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52689
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0006528
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: