Provider Demographics
NPI:1124111976
Name:MCMILLAN, KIMBERLY SUE (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:MCMILLAN
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 1:2910 BETTEN DR
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:NE
Mailing Address - Zip Code:68333-3084
Mailing Address - Country:US
Mailing Address - Phone:402-826-2102
Mailing Address - Fax:
Practice Address - Street 1:2910 BETTEN DR
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:NE
Practice Address - Zip Code:68333-3084
Practice Address - Country:US
Practice Address - Phone:402-826-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A1878Medicare ID - Type Unspecified
TX8L14370Medicare PIN
TXP14511Medicare UPIN
TX8L14369Medicare PIN
TX8L14448Medicare PIN