Provider Demographics
NPI:1144295528
Name:KIMBROUGH, STEPHANIE THOMPSON (PA)
Entity type:Individual
Prefix:PROF
First Name:STEPHANIE
Middle Name:THOMPSON
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PARK CENTRAL DR
Mailing Address - Street 2:200
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6469
Mailing Address - Country:US
Mailing Address - Phone:803-252-9907
Mailing Address - Fax:803-252-9906
Practice Address - Street 1:121 PARK CENTRAL DR
Practice Address - Street 2:200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6469
Practice Address - Country:US
Practice Address - Phone:803-252-9907
Practice Address - Fax:803-252-9906
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPMA711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC204037836Medicare ID - Type Unspecified
SCP378362040Medicare PIN
SCP37836Medicare UPIN