Provider Demographics
NPI:1164058277
Name:GROME, KIMBERLY ANNE KUMIKO (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE KUMIKO
Last Name:GROME
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:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:6001 N MAYFAIR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1129
Practice Address - Country:US
Practice Address - Phone:509-462-2273
Practice Address - Fax:509-462-2275
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1969363A00000X
WA61077701363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty