Provider Demographics
NPI:1700202637
Name:VOSBURGH, KIMBERLIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:A
Last Name:VOSBURGH
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 1:2000 S WHEELING AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5647
Mailing Address - Country:US
Mailing Address - Phone:918-748-7810
Mailing Address - Fax:918-403-6437
Practice Address - Street 1:2000 S WHEELING AVE STE 701
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5647
Practice Address - Country:US
Practice Address - Phone:918-748-7810
Practice Address - Fax:918-403-6437
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01684363A00000X
OK3096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002428OtherMEDICARE PTAN
KS201092230BMedicaid