Healthcare Provider Details

I. General information

NPI: 1629114608
Provider Name (Legal Business Name): KIMBERLY RUTH TUPPER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 W LINCOLN HWY
EXTON PA
19341-2547
US

IV. Provider business mailing address

770 W LINCOLN HWY
EXTON PA
19341-2547
US

V. Phone/Fax

Practice location:
  • Phone: 610-269-1372
  • Fax: 610-269-6951
Mailing address:
  • Phone: 610-269-1372
  • Fax: 610-269-6951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA000144L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier232769426
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerTAX ID
# 2
IdentifierP00079110
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: