Provider Demographics
NPI:1578013397
Name:BADE, KIMBERLY IRENE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:IRENE
Last Name:BADE
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 1:1229 N ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3630
Mailing Address - Country:US
Mailing Address - Phone:248-765-9919
Mailing Address - Fax:
Practice Address - Street 1:47601 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1233
Practice Address - Country:US
Practice Address - Phone:248-849-8721
Practice Address - Fax:248-849-8507
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109996363AS0400X
MI5601007904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical