Provider Demographics
NPI:1689837775
Name:HALL, KEVIN MICHAEL (PA-AA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:HALL
Suffix:
Gender:M
Credentials:PA-AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 EASTLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:816-932-9089
Practice Address - Street 1:35 COLLIER RD NW STE 775
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1608
Practice Address - Country:US
Practice Address - Phone:404-605-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5874207L00000X, 363A00000X, 367H00000X
WAPA10004213363A00000X
MO2020020930367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant