Healthcare Provider Details

I. General information

NPI: 1780302539
Provider Name (Legal Business Name): KEVIN ROBERT KEMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 UNIVERSITY TOWN CENTRE DR
MORGANTOWN WV
26501-2421
US

IV. Provider business mailing address

511 MELROSE ST
MORGANTOWN WV
26505-4726
US

V. Phone/Fax

Practice location:
  • Phone: 855-988-2273
  • Fax: 304-285-7372
Mailing address:
  • Phone: 801-919-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2884
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: