Provider Demographics
NPI:1518528231
Name:ANDERSON, KEVIN J
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WELLNESS WAY
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6797
Mailing Address - Country:US
Mailing Address - Phone:814-231-7000
Mailing Address - Fax:814-231-7098
Practice Address - Street 1:155 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6797
Practice Address - Country:US
Practice Address - Phone:814-237-4321
Practice Address - Fax:814-235-0484
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant