Healthcare Provider Details

I. General information

NPI: 1215846720
Provider Name (Legal Business Name): KEVIN THOMAS ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MARYLAND RD STE 20
WILLOW GROVE PA
19090-1732
US

IV. Provider business mailing address

488 HERALD DR
AMBLER PA
19002-1530
US

V. Phone/Fax

Practice location:
  • Phone: 800-321-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA068130
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: