Provider Demographics
NPI:1528619517
Name:MCCLUNG, KEVAN DOUGLAS (PA-C)
Entity type:Individual
Prefix:
First Name:KEVAN
Middle Name:DOUGLAS
Last Name:MCCLUNG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2508
Mailing Address - Country:US
Mailing Address - Phone:336-716-8200
Mailing Address - Fax:
Practice Address - Street 1:131 MILLER ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2508
Practice Address - Country:US
Practice Address - Phone:336-716-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-22
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant