Provider Demographics
NPI:1528139821
Name:HAUCH, KIMBERLY JO (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:HAUCH
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 1:251 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4872
Mailing Address - Country:US
Mailing Address - Phone:320-251-8181
Mailing Address - Fax:320-251-6942
Practice Address - Street 1:1301 33RD ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9668
Practice Address - Country:US
Practice Address - Phone:320-251-8181
Practice Address - Fax:320-251-6942
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9021363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN731174500Medicaid
MNR04649Medicare UPIN
MN970005024Medicare PIN