Basic Information
| Provider Information | |||||||||
| NPI: | 1285293969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATUM | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6673 E CORNELL AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595777872 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 MALL DR | ||||||||
| Address2: | |||||||||
| City: | HANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932305786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595829000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 95045187 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 367500000X | 95001171 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.