Provider Demographics
NPI:1740218999
Name:CANTILLON, KIMBERLY T (PA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:T
Last Name:CANTILLON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:T
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:39450 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3600
Mailing Address - Country:US
Mailing Address - Phone:313-461-4632
Mailing Address - Fax:
Practice Address - Street 1:39450 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3600
Practice Address - Country:US
Practice Address - Phone:313-461-4632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004760363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5301004760OtherLICENSE