Provider Demographics
NPI:1669453221
Name:COLE, KIM G (PA)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:G
Last Name:COLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 LAKE MIRIAM DR STE S1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2188
Mailing Address - Country:US
Mailing Address - Phone:863-647-2333
Mailing Address - Fax:863-644-6729
Practice Address - Street 1:202 LAKE MIRIAM DR STE S1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2188
Practice Address - Country:US
Practice Address - Phone:863-647-2333
Practice Address - Fax:863-393-1995
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2993363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA2993OtherSTATE LICENSE
FL10679201OtherCITRUS HEALTHCARE
FLE6191ZMedicare ID - Type Unspecified
FLP40057Medicare UPIN