Provider Demographics
NPI:1679626840
Name:HUMPHRIES, KIMBERLY S (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:HUMPHRIES
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 1:141 N. EAGLE CREEK DRIVE, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-266-2273
Mailing Address - Fax:859-266-2274
Practice Address - Street 1:141 N EAGLE CREEK DR STE 200
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2538
Practice Address - Country:US
Practice Address - Phone:859-543-1000
Practice Address - Fax:859-543-0399
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA736363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100051870Medicaid
KYK037711Medicare PIN