Basic Information
| Provider Information | |||||||||
| NPI: | 1487022091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRELL | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50973 COUNTY ROAD 681 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490649048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178987718 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Practice Location | |||||||||
| Address1: | 50973 COUNTY ROAD 681 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490649048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692412220 | ||||||||
| FaxNumber: | 2696744239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2015 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601007459 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5601007459 | 01 | MI | PHYSICIAN ASSISTANT TEMPORARY LICENSE | OTHER |