Provider Demographics
NPI:1083228738
Name:OBIDIEGWU, KIMBERLY LAVERNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LAVERNE
Last Name:OBIDIEGWU
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 1:40370 ROAD 222
Mailing Address - Street 2:
Mailing Address - City:BASS LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:93604-9702
Mailing Address - Country:US
Mailing Address - Phone:559-779-7438
Mailing Address - Fax:
Practice Address - Street 1:1207 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3235
Practice Address - Country:US
Practice Address - Phone:559-432-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
CAPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty