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General NPI Number Information
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NPI Number | 1295955441
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Entity Type | Individual
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Provider Name | KEVIN CLARK ROBERTSON PA
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Gender | Male
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Dates
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Enumeration Date | 04/30/2007
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Last Update Date | 08/14/2015
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Provider Practice Location Address
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Address Line | 125 EUCALYPTUS DR
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City | EL SEGUNDO
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State | CA
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Zip | 90245-3839
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Country | US
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Telephone | 310-322-4278
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Fax | 310-322-6660
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Provider Business Mailing Address
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Address Line | 444 S SAN VICENTE BLVD SUITE 800
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City | LOS ANGELES
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State | CA
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Zip | 90048
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Country | US
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Telephone | 310-423-9716
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA17110
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License Number State | CA
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