Provider Demographics
NPI:1184685794
Name:DAVENPORT, KEVAN EDWARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVAN
Middle Name:EDWARD
Last Name:DAVENPORT
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 1:9517 ANGELINA CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5114
Mailing Address - Country:US
Mailing Address - Phone:410-477-1800
Mailing Address - Fax:
Practice Address - Street 1:9600 N POINT RD
Practice Address - Street 2:
Practice Address - City:FORT HOWARD
Practice Address - State:MD
Practice Address - Zip Code:21052-3050
Practice Address - Country:US
Practice Address - Phone:410-477-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000839363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical