Healthcare Provider Details

I. General information

NPI: 1588853675
Provider Name (Legal Business Name): KEVIN JOHN WANSOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICAL CENTER BLVD SUITE 303 CLINICAL RENAL ASSOCIATES LTD
UPLAND PA
19013-3995
US

IV. Provider business mailing address

30 MEDICAL CENTER BLVD SUITE 303 CLINICAL RENAL ASSOCIATES LTD
UPLAND PA
19013-3995
US

V. Phone/Fax

Practice location:
  • Phone: 610-872-8501
  • Fax: 610-872-5188
Mailing address:
  • Phone: 610-872-8501
  • Fax: 610-872-5188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053066
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: