Provider Demographics
NPI:1093099491
Name:ROYCROFT, KIM ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ELLEN
Last Name:ROYCROFT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TRENTON RD
Mailing Address - Street 2:
Mailing Address - City:BROWNS MILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:08015-1705
Mailing Address - Country:US
Mailing Address - Phone:609-893-1200
Mailing Address - Fax:
Practice Address - Street 1:200 TRENTON RD
Practice Address - Street 2:
Practice Address - City:BROWNS MILLS
Practice Address - State:NJ
Practice Address - Zip Code:08015-1705
Practice Address - Country:US
Practice Address - Phone:609-893-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011654363A00000X
NJ25MP00256100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant