Individual
KEVIN MICAEL MITCHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
740 S LIMESTONE STE L119, LEXINGTON, KY 40536-1239
(859) 257-3253
(859) 323-1203
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
10003888A
IN
363A00000X
Physician Assistant
2796
TN
363A00000X
Physician Assistant
Primary
TC110
KY
363AM0700X
Medical Physician Assistant
2796
TN
363AM0700X
Medical Physician Assistant
TC110
KY
363AS0400X
Surgical Physician Assistant
2796
TN
363AS0400X
Surgical Physician Assistant
TC110
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
233690173
MEDICARE
IN
05
—
300070423
—
IN
Enumeration date
07/09/2015
Last updated
12/19/2024
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