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NPI Code Detail

MEDICARE: KAITLYN SHANE KIMBROUGH PA-C

MEDICARE: KAITLYN SHANE KIMBROUGH 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
1363A00000XPhysician AssistantPA16774TX

General Provider Information

NPI Number : 1912601733
Entity Type Code : Individual
Provider Name (Legal Business Name) : KAITLYN SHANE KIMBROUGH PA-C
Provider Business Mailing Address
First Line : PO BOX 733784
Second Line :
City : DALLAS
State : TX
Zip : 75373-3784
Country : US
Telephone Number : 682-885-6483
Fax Number : 682-885-3113
Provider Business Practice Location Address
First Line : 1500 COOPER ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-2710
Country : US
Telephone Number : 682-885-2500
Fax Number : 682-885-2510
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/27/2023
Last Update Date : 02/03/2026

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Directions to “ KAITLYN SHANE KIMBROUGH PA-C” Practice Location

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