Provider Demographics
NPI:1770899551
Name:PROVOAST, KIMBERLY K (PA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:K
Last Name:PROVOAST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:K
Other - Last Name:ROSEBRUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:337 E HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1127
Mailing Address - Country:US
Mailing Address - Phone:989-345-5240
Mailing Address - Fax:989-345-4513
Practice Address - Street 1:337 E HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1127
Practice Address - Country:US
Practice Address - Phone:989-345-5240
Practice Address - Fax:989-345-4513
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629110556OtherGROUP NPI
MI5601005840OtherMI LICENSE NUMBER