Provider Demographics
NPI:1033176219
Name:KIMMEL, JASON B (PAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:B
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WEST 98TH STREET
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-4773
Mailing Address - Country:US
Mailing Address - Phone:952-881-2651
Mailing Address - Fax:952-885-6065
Practice Address - Street 1:600 WEST 98TH STREET
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4773
Practice Address - Country:US
Practice Address - Phone:952-881-2651
Practice Address - Fax:952-885-6065
Is Sole Proprietor?:No
Enumeration Date:2006-04-29
Last Update Date:2012-04-05
Deactivation Date:2011-09-12
Deactivation Code:
Reactivation Date:2011-10-06
Provider Licenses
StateLicense IDTaxonomies
MN9569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant