Provider Demographics
NPI:1144240268
Name:TENOLD, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:TENOLD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 AVIATION DR STE 203
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8785
Practice Address - Country:US
Practice Address - Phone:208-727-8295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102487207R00000X, 363A00000X
IDPA-2160363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
538872Medicare UPIN
NC2752566BMedicare ID - Type UnspecifiedPART B