Provider Demographics
NPI:1275702292
Name:MCCAUGHAN, KIMBERLY WALTON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:WALTON
Last Name:MCCAUGHAN
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Gender:F
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:920 2ND AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-3318
Mailing Address - Country:US
Mailing Address - Phone:612-659-7111
Mailing Address - Fax:612-659-7101
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:612-659-7111
Practice Address - Fax:612-659-7101
Is Sole Proprietor?:No
Enumeration Date:2008-02-24
Last Update Date:2009-01-12
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Provider Licenses
StateLicense IDTaxonomies
TXPA04378363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K7107Medicare PIN