Basic Information
| Provider Information | |||||||||
| NPI: | 1295955441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 S SAN VICENTE BLVD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104239716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 EUCALYPTUS DR | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902453839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103224278 | ||||||||
| FaxNumber: | 3103226660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA17110 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA17110 | 01 | CA | MEDICAL LICENSE | OTHER |