Provider Demographics
NPI:1376687764
Name:KIMMINS, KEVIN (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KIMMINS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 COLLIERS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5014
Mailing Address - Country:US
Mailing Address - Phone:304-797-6000
Mailing Address - Fax:
Practice Address - Street 1:601 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5014
Practice Address - Country:US
Practice Address - Phone:304-797-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59986367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
550387249OtherTAX ID
WV38010004792Medicaid
KI7338711Medicare PIN