Individual
MRS. KIMBERLY K PROVOAST
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
337 E HOUGHTON AVE, WEST BRANCH, MI 48661-1127
(989) 345-5240
(989) 345-4513
Mailing address
337 E HOUGHTON AVE, WEST BRANCH, MI 48661-1127
(989) 345-5240
(989) 345-4513
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5601005840
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1629110556
GROUP NPI
MI
01
—
5601005840
MI LICENSE NUMBER
MI
Enumeration date
08/31/2010
Last updated
10/18/2012
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