Provider Demographics
NPI:1225059561
Name:KIRKEBY, KATHY A (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:KIRKEBY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:A
Other - Last Name:WUSSOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:820 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-7544
Mailing Address - Fax:701-234-7577
Practice Address - Street 1:820 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-7544
Practice Address - Fax:701-234-7577
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0130363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND71174Medicaid
MN430620100Medicaid
NDN14296Medicare PIN
ND71174Medicaid