Provider Demographics
NPI:1891872933
Name:HOVSEPIAN, KIMBERLY S (PA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:S
Last Name:HOVSEPIAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 E RIVER RD
Mailing Address - Street 2:PO BOX 474
Mailing Address - City:NEWKIRK
Mailing Address - State:OK
Mailing Address - Zip Code:74647-7517
Mailing Address - Country:US
Mailing Address - Phone:580-362-1039
Mailing Address - Fax:580-362-2988
Practice Address - Street 1:3151 E RIVER RD
Practice Address - Street 2:
Practice Address - City:NEWKIRK
Practice Address - State:OK
Practice Address - Zip Code:74647-7517
Practice Address - Country:US
Practice Address - Phone:580-362-1039
Practice Address - Fax:580-362-2988
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500651363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKTEZKKLZR7MOtherMEDICARE PTAN
KS100321990AMedicaid