Provider Demographics
NPI:1760475651
Name:MEYER, KIMBERLY E (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:MEYER
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 1:1435 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:PLAIN DEALING
Mailing Address - State:LA
Mailing Address - Zip Code:71064-4223
Mailing Address - Country:US
Mailing Address - Phone:318-813-2921
Mailing Address - Fax:318-813-2915
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPT. OF NEUROSURGERY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2921
Practice Address - Fax:318-813-2915
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10325.RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625761Medicaid
LA5CB32P600Medicare ID - Type UnspecifiedMEDICARE NUMBER
LA1625761Medicaid