Provider Demographics
NPI:1033701719
Name:LAROSE, KEVIN LEE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:LAROSE
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-2603
Mailing Address - Country:US
Mailing Address - Phone:315-772-2778
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-2603
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1178786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant