Provider Demographics
NPI:1891208658
Name:FEITOSA, KIMBERLY NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:FEITOSA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICOLE
Other - Last Name:EBERHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4305 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-1371
Mailing Address - Country:US
Mailing Address - Phone:570-561-4855
Mailing Address - Fax:
Practice Address - Street 1:305 S 5TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5832
Practice Address - Country:US
Practice Address - Phone:580-289-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical