Provider Demographics
NPI:1346399045
Name:HERRON, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HERRON
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 1:1315 LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6845
Mailing Address - Country:US
Mailing Address - Phone:580-286-3328
Mailing Address - Fax:580-286-2444
Practice Address - Street 1:1315 LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6845
Practice Address - Country:US
Practice Address - Phone:580-286-3328
Practice Address - Fax:580-286-2444
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1550363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical