MEDICARE: MISS KIMBERLY ANN BURGESS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	3292	TN

General Provider Information

NPI Number	:	1043429202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KIMBERLY ANN BURGESS PA-C

Provider Business Mailing Address
First Line	:	1509 OLD COWAN RD
Second Line	:
City	:	WINCHESTER
State	:	TN
Zip	:	37398-1913
Country	:	US
Telephone Number	:	931-962-1004
Fax Number	:	931-962-1400

Provider Business Practice Location Address
First Line	:	2656 BLUE CYPRESS LAKE CT
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2912
Country	:	US
Telephone Number	:	954-448-5636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	08/31/2017

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