Provider Demographics
NPI:1740432814
Name:KILGORE, KINSHASA D (PA)
Entity Type:Individual
Prefix:
First Name:KINSHASA
Middle Name:D
Last Name:KILGORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 MARTIN LUTHER KING JR AVE SW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1131
Mailing Address - Country:US
Mailing Address - Phone:571-249-3487
Mailing Address - Fax:
Practice Address - Street 1:2131 DAVIDSONVILLE RD
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1632
Practice Address - Country:US
Practice Address - Phone:410-721-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06008363A00000X
390200000X
MDC05240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y8981OtherBCBS
TX198312401Medicaid
TX8L4714Medicare PIN