Provider Demographics
NPI:1639485527
Name:PARKS, KIMBERLEE M (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:M
Last Name:PARKS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:M
Other - Last Name:LONGHINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:STE. 334
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3870
Mailing Address - Fax:906-225-3975
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 342
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3870
Practice Address - Fax:906-225-3975
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005833363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical