Provider Demographics
NPI:1780646612
Name:PORTER, KIMBERLY JEAN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JEAN
Last Name:PORTER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:JEAN
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:243 CURTISS RD
Practice Address - Street 2:
Practice Address - City:BARKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2425
Practice Address - Country:US
Practice Address - Phone:318-456-7320
Practice Address - Fax:318-456-6246
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1070445OtherNCCPA