Provider Demographics
NPI:1912601733
Name:KIMBROUGH, KAITLYN SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:SHANE
Last Name:KIMBROUGH
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 1:1600 SAXONY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-1974
Mailing Address - Country:US
Mailing Address - Phone:832-696-3233
Mailing Address - Fax:
Practice Address - Street 1:2975 E BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9186
Practice Address - Country:US
Practice Address - Phone:682-518-8619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant