Provider Demographics
NPI:1942789151
Name:MORA, KEVIN PATRICIO (PA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PATRICIO
Last Name:MORA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 WACKEMAN CT
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3779
Mailing Address - Country:US
Mailing Address - Phone:614-940-1048
Mailing Address - Fax:
Practice Address - Street 1:111 S GRANT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4701
Practice Address - Country:US
Practice Address - Phone:614-566-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical