Provider Demographics
NPI:1922073709
Name:TRAHAN, KIM LAUREN (PA)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:LAUREN
Last Name:TRAHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 IVY ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1627
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2071
Practice Address - Street 1:421 PLAZA DR
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3658
Practice Address - Country:US
Practice Address - Phone:607-771-1700
Practice Address - Fax:607-873-1824
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006561-1363A00000X
PAMA002671L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACC9269OtherRR MEDICARE GROUP
PAGU039830OtherPA MEDICARE GROUP
PA970020849OtherRR MEDICARE PIN
PA018107N9SMedicare PIN
PA970020849OtherRR MEDICARE PIN