Provider Demographics
NPI:1093782914
Name:WALLER, KIMBERLY L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:L
Last Name:WALLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:COLPITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1051
Mailing Address - Country:US
Mailing Address - Phone:541-471-3455
Mailing Address - Fax:
Practice Address - Street 1:1701 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1051
Practice Address - Country:US
Practice Address - Phone:541-471-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA842363AM0700X
ORPA01142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503581Medicaid
NV100503226Medicaid
S95176Medicare UPIN
NV100503226Medicaid
ORR135326Medicare PIN