Provider Demographics
NPI:1699739227
Name:COLGAN, KIMEN M (PA)
Entity type:Individual
Prefix:
First Name:KIMEN
Middle Name:M
Last Name:COLGAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:575 PRICE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2553
Mailing Address - Country:US
Mailing Address - Phone:805-481-3685
Mailing Address - Fax:805-481-5245
Practice Address - Street 1:575 PRICE ST
Practice Address - Street 2:SUITE101
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2553
Practice Address - Country:US
Practice Address - Phone:805-481-3685
Practice Address - Fax:805-481-5245
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2016-09-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI1366363AS0400X
AZ3531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41929300Medicaid
P32899Medicare UPIN
WI084F15875Medicare ID - Type Unspecified