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General NPI Number Information
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NPI Number | 1790336709
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Entity Type | Individual
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Provider Name | KEVIN NOLAN ANDERSON
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Gender | Male
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Dates
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Enumeration Date | 09/23/2019
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Last Update Date | 09/23/2019
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Provider Practice Location Address
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Address Line | 3401 CIVIC CENTER BLVD
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City | PHILADELPHIA
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State | PA
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Zip | 19104-4319
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Country | US
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Telephone | 215-590-1000
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Fax |
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Provider Business Mailing Address
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Address Line | 2001 SPRING GARDEN ST APT 203
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City | PHILADELPHIA
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State | PA
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Zip | 19130-5011
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Country | US
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Telephone | 315-730-9398
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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 | MA060948
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License Number State | PA
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