Provider Demographics
NPI:1043554868
Name:SEDBROOK, KIMBERLY JO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JO
Last Name:SEDBROOK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 CARLSON PKWY N STE 240
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4485
Mailing Address - Country:US
Mailing Address - Phone:763-367-7110
Mailing Address - Fax:
Practice Address - Street 1:2 CARLSON PKWY N STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4467
Practice Address - Country:US
Practice Address - Phone:952-473-1286
Practice Address - Fax:952-473-7281
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11222207N00000X, 363A00000X
WI3284-23363A00000X
COPA.0004420363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical