Healthcare Provider Details

I. General information

NPI: 1558300863
Provider Name (Legal Business Name): KIMBERLY S HURST PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17717 MASONIC
FRASER MI
48026-3158
US

IV. Provider business mailing address

17717 MASONIC
FRASER MI
48026-3158
US

V. Phone/Fax

Practice location:
  • Phone: 586-294-0600
  • Fax:
Mailing address:
  • Phone: 586-294-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003608
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: