Provider Demographics
NPI:1568747939
Name:HOGGE, KIMBERLE LYNNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLE
Middle Name:LYNNE
Last Name:HOGGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KIMBERLE
Other - Middle Name:LYNNE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11315 PEMBROOKE SQ
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4806
Mailing Address - Country:US
Mailing Address - Phone:301-843-7232
Mailing Address - Fax:
Practice Address - Street 1:11315 PEMBROOKE SQ
Practice Address - Street 2:SUITE 110
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4806
Practice Address - Country:US
Practice Address - Phone:301-843-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030787363A00000X
COPA0003586363A00000X
MDC05727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15223531Medicaid
CO23375OtherKAISER COMMERCIAL NUMBER
CO15223531Medicaid