Provider Demographics
NPI:1023083144
Name:EARLYWINE, KEVIN (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:EARLYWINE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 S CLEARVIEW AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3378
Mailing Address - Country:US
Mailing Address - Phone:480-988-9108
Mailing Address - Fax:480-813-4460
Practice Address - Street 1:40773 N IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7002
Practice Address - Country:US
Practice Address - Phone:602-714-1271
Practice Address - Fax:480-987-6566
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z173812OtherMEDICARE PTAN
AZ501347Medicaid
AZ501347Medicaid