Provider Demographics
NPI:1447590237
Name:HENEGHAN, KIM MORIAH (PA-C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MORIAH
Last Name:HENEGHAN
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 1:4140 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3825
Mailing Address - Country:US
Mailing Address - Phone:718-784-2240
Mailing Address - Fax:718-683-5757
Practice Address - Street 1:4140 27TH ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3825
Practice Address - Country:US
Practice Address - Phone:718-784-2240
Practice Address - Fax:718-683-5757
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016200-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant