Healthcare Provider Details

I. General information

NPI: 1538164389
Provider Name (Legal Business Name): KEVIN KUSCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 QUITMAN ST
PITTSBURG TX
75686-1032
US

IV. Provider business mailing address

5239 FM 1649
GILMER TX
75645-6541
US

V. Phone/Fax

Practice location:
  • Phone: 903-856-4242
  • Fax: 903-856-4244
Mailing address:
  • Phone: 903-797-2088
  • Fax: 903-797-2128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01209
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: