MEDICARE: MR. KEVIN JOHN WANSOR PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA053066	PA

General Provider Information

NPI Number	:	1588853675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN JOHN WANSOR PA-C

Provider Business Mailing Address
First Line	:	30 MEDICAL CENTER BLVD SUITE 303
Second Line	:	CLINICAL RENAL ASSOCIATES LTD
City	:	UPLAND
State	:	PA
Zip	:	19013-3995
Country	:	US
Telephone Number	:	610-872-8501
Fax Number	:	610-872-5188

Provider Business Practice Location Address
First Line	:	30 MEDICAL CENTER BLVD SUITE 303
Second Line	:	CLINICAL RENAL ASSOCIATES LTD
City	:	UPLAND
State	:	PA
Zip	:	19013-3995
Country	:	US
Telephone Number	:	610-872-8501
Fax Number	:	610-872-5188

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	12/20/2013

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