Provider Demographics
NPI:1194832006
Name:HISSONG, KIMBERLY K (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
Last Name:HISSONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 WATT AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-3600
Mailing Address - Country:US
Mailing Address - Phone:916-481-6800
Mailing Address - Fax:916-481-1881
Practice Address - Street 1:3315 WATT AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-3600
Practice Address - Country:US
Practice Address - Phone:916-481-6800
Practice Address - Fax:916-481-1881
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT185262-1205207L00000X
CAC139617207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107005891101OtherIHC
UT36403OtherPEHP
UT416939OtherDESERET MUTUAL
CA09300OtherVALLEY CHILDRENS HEALTHCARE
UTPR00880OtherMOLINA
UT2403OtherHEALTHY U
UT002084559OtherFIRST HEALTH
UT870280408HI1OtherEDUCATORS MUTUAL
UT2000040OtherUNITED HEALTHCARE
UTQM0000049524OtherALTIUS
ID002966900Medicaid
WY111000400Medicaid
MT401765Medicaid