Provider Demographics
NPI:1265826275
Name:KILIAN, KIMBERLY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:KILIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:WISNIEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:17799 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-1173
Mailing Address - Country:US
Mailing Address - Phone:810-656-9840
Mailing Address - Fax:
Practice Address - Street 1:60 W BIG BEAVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3913
Practice Address - Country:US
Practice Address - Phone:248-258-5100
Practice Address - Fax:248-258-5110
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007307363A00000X
NY018586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant