Provider Demographics
NPI:1578526885
Name:BRABHAM, KIKI D (PA)
Entity Type:Individual
Prefix:
First Name:KIKI
Middle Name:D
Last Name:BRABHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S COULTER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1763
Mailing Address - Country:US
Mailing Address - Phone:806-358-9911
Mailing Address - Fax:806-358-3728
Practice Address - Street 1:1301 S COULTER ST
Practice Address - Street 2:SUITE 405
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1763
Practice Address - Country:US
Practice Address - Phone:806-358-9111
Practice Address - Fax:806-358-3728
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9128OtherBLUE SHIELD
TXQ20417Medicare UPIN
TX8G0739Medicare ID - Type Unspecified