Provider Demographics
NPI:1710902986
Name:KILBOURN, KENT J (PA)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:J
Last Name:KILBOURN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:STE 1003
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5529
Mailing Address - Country:US
Mailing Address - Phone:203-853-0003
Mailing Address - Fax:
Practice Address - Street 1:148 EAST AVE
Practice Address - Street 2:SUITE 3D
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5721
Practice Address - Country:US
Practice Address - Phone:203-853-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
595809Medicare UPIN