Provider Demographics
NPI:1598737975
Name:RACINE, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:RACINE
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 1:3850 N GRANT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538
Mailing Address - Country:US
Mailing Address - Phone:970-624-5170
Mailing Address - Fax:970-669-7521
Practice Address - Street 1:3850 N GRANT AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8431
Practice Address - Country:US
Practice Address - Phone:970-624-5170
Practice Address - Fax:970-669-7521
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61624349Medicaid
COP00944762OtherMEDICARE RAILROAD CARRIER PTAN
CO61624349Medicaid
COC463208Medicare PIN
COP58101Medicare UPIN