Provider Demographics
NPI:1407164742
Name:PENGRA, KIMBERLY R (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:PENGRA
Suffix:
Gender:F
Credentials:PA
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Other - Last Name:
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Mailing Address - Street 1:23222 KINGSLAND BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-3033
Mailing Address - Country:US
Mailing Address - Phone:281-693-0084
Mailing Address - Fax:281-693-0093
Practice Address - Street 1:23222 KINGSLAND BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-3033
Practice Address - Country:US
Practice Address - Phone:281-693-0084
Practice Address - Fax:281-693-0093
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1407164742OtherBLUE CROSS BLUE SHIELD
TXTXB114094Medicare PIN