Provider Demographics
NPI:1053838367
Name:KUPPENHEIMER, KIMBERLY COLLEEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:COLLEEN
Last Name:KUPPENHEIMER
Suffix:
Gender:F
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 1:1735 BRANTFEATHER GRV
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-6907
Mailing Address - Country:US
Mailing Address - Phone:719-344-8564
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIRCLE
Practice Address - Street 2:FORT CARSON, EVANS ARMY HOSPITAL, WARRIOR CLINIC
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-526-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0005100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant