Provider Demographics
NPI:1104267749
Name:RUHLIN PRIMM, KATHLEEN MCKENNA (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MCKENNA
Last Name:RUHLIN PRIMM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 KINGSLEY AVE. SUITE 1900
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-1559
Mailing Address - Country:US
Mailing Address - Phone:904-276-2549
Mailing Address - Fax:904-276-9235
Practice Address - Street 1:1887 KINGSLEY AVE. SUITE 1900
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-1559
Practice Address - Country:US
Practice Address - Phone:904-276-2549
Practice Address - Fax:904-276-9235
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003862363AS0400X
FLPA9109278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0093695Medicaid
OHH214430Medicare PIN