Provider Demographics
NPI:1821273004
Name:KINKADE, KIKI JOHN (PT)
Entity Type:Individual
Prefix:
First Name:KIKI
Middle Name:JOHN
Last Name:KINKADE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-5840
Mailing Address - Country:US
Mailing Address - Phone:520-694-1268
Mailing Address - Fax:520-694-3089
Practice Address - Street 1:655 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5840
Practice Address - Country:US
Practice Address - Phone:520-694-1268
Practice Address - Fax:520-694-3089
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104177Medicare PIN