Basic Information
| Provider Information | |||||||||
| NPI: | 1568455384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKREL | ||||||||
| FirstName: | KEVAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9225 N 3RD ST | ||||||||
| Address2: | STE 304 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024450751 | ||||||||
| FaxNumber: | 6024248128 | ||||||||
| Practice Location | |||||||||
| Address1: | 9225 N 3RD ST | ||||||||
| Address2: | STE 304 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024450751 | ||||||||
| FaxNumber: | 6024248128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 08/21/2009 | ||||||||
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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 | 207R00000X | 30069 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 715550 | 05 | AZ | MEDICAID |