Basic Information
| Provider Information | |||||||||
| NPI: | 1164425633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDUS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LAMAR | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3811 E BELL RD STE 309 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804200749 | ||||||||
| FaxNumber: | 4804200732 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286845421 | ||||||||
| FaxNumber: | 2896847457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2477 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 2477 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | AZ0146700 | 01 | AZ | BLUE CROSS BLUE SHIELD AZ | OTHER | 577786001 | 05 | AZ | MEDICAID |