Provider Demographics
NPI:1538164389
Name:KUSCH, KEVIN (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KUSCH
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 1:5239 FM 1649
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75645-6541
Mailing Address - Country:US
Mailing Address - Phone:903-797-2088
Mailing Address - Fax:903-797-2128
Practice Address - Street 1:408 QUITMAN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-1032
Practice Address - Country:US
Practice Address - Phone:903-856-4242
Practice Address - Fax:903-856-4244
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C9718Medicare ID - Type Unspecified
TXS06760Medicare UPIN