Provider Demographics
NPI:1114087145
Name:BELLOWS, KIM (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BELLOWS
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 1:18 PENINSULA CT
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-4811
Mailing Address - Country:US
Mailing Address - Phone:310-704-8322
Mailing Address - Fax:
Practice Address - Street 1:3434 VILLA LN
Practice Address - Street 2:SUITE 150
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6405
Practice Address - Country:US
Practice Address - Phone:707-252-9660
Practice Address - Fax:707-252-9610
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15150363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical