Provider Demographics
NPI:1144669193
Name:PFISTER, KEVIN M (PA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:PFISTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 SEAN HAGGERTY DR APT 2114
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3394
Mailing Address - Country:US
Mailing Address - Phone:832-621-5946
Mailing Address - Fax:
Practice Address - Street 1:10301 GATEWAY BLVD W
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-7701
Practice Address - Country:US
Practice Address - Phone:915-595-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08809363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX330477601Medicaid
TX334325YKN5Medicare PIN