Provider Demographics
NPI:1629114608
Name:TUPPER, KIMBERLY RUTH (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RUTH
Last Name:TUPPER
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 1:770 W LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2547
Mailing Address - Country:US
Mailing Address - Phone:610-269-1372
Mailing Address - Fax:610-269-6951
Practice Address - Street 1:770 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2547
Practice Address - Country:US
Practice Address - Phone:610-269-1372
Practice Address - Fax:610-269-6951
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000144L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232769426OtherTAX ID
PAP00079110OtherRAILROAD MEDICARE
PAS56633Medicare UPIN
PA232769426OtherTAX ID