Provider Demographics
NPI:1851512214
Name:HORTON, KIMBERLEE J (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:J
Last Name:HORTON
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 1:390 MAIN ST
Mailing Address - Street 2:STE 509
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2581
Mailing Address - Country:US
Mailing Address - Phone:508-753-4151
Mailing Address - Fax:508-753-4151
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1110Medicare ID - Type Unspecified
MAS89509Medicare UPIN