1275702292 NPI number — MRS. KIMBERLY WALTON MCCAUGHAN PHYSICIAN ASSISTANT

Table of content: MRS. KIMBERLY WALTON MCCAUGHAN PHYSICIAN ASSISTANT (NPI 1275702292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275702292 NPI number — MRS. KIMBERLY WALTON MCCAUGHAN PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAUGHAN
Provider First Name:
KIMBERLY
Provider Middle Name:
WALTON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275702292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
920 2ND AVE S
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55402-3318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-659-7111
Provider Business Mailing Address Fax Number:
612-659-7101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 2ND AVE S
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55402-3318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-659-7111
Provider Business Practice Location Address Fax Number:
612-659-7101
Provider Enumeration Date:
02/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA04378 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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