Provider Demographics
NPI:1902811698
Name:PROUGH, KIMBERLY J (PAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:PROUGH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 HIGHWAY A1A
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4922
Mailing Address - Country:US
Mailing Address - Phone:321-777-2273
Mailing Address - Fax:321-779-7425
Practice Address - Street 1:2254 HIGHWAY A1A
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4922
Practice Address - Country:US
Practice Address - Phone:321-777-2273
Practice Address - Fax:321-779-7425
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104973363A00000X
TXPA02977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N8636OtherBLUECROSS BLUESHIELD
TX8Y0826OtherBLUE CROSS BLUE SHIELD
TX8D1531Medicare PIN
Q34057Medicare UPIN
TX8J3254Medicare PIN
TX8N8636OtherBLUECROSS BLUESHIELD
TXP00246854Medicare PIN