Provider Demographics
NPI:1871934018
Name:KAVANAGH, KIMBERLY ANN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ANN
Last Name:KAVANAGH
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 1:1850 E PARK AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6706
Mailing Address - Country:US
Mailing Address - Phone:814-278-4680
Mailing Address - Fax:814-235-1523
Practice Address - Street 1:1850 E PARK AVE STE 302
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803
Practice Address - Country:US
Practice Address - Phone:814-278-4680
Practice Address - Fax:814-235-1523
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003060363A00000X
PAMA056146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant