Basic Information
| Provider Information | |||||||||
| NPI: | 1669453221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLE | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 LAKE MIRIAM DR STE S1 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636472333 | ||||||||
| FaxNumber: | 8636446729 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 LAKE MIRIAM DR STE S1 | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636472333 | ||||||||
| FaxNumber: | 8633931995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 2993 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA2993 | 01 | FL | STATE LICENSE | OTHER | 10679201 | 01 | FL | CITRUS HEALTHCARE | OTHER |