Provider Demographics
NPI:1275503989
Name:ROBERTS-MITCHELL, KIMBERLY (PAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ROBERTS-MITCHELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 NORTH WALDRON
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502
Mailing Address - Country:US
Mailing Address - Phone:620-669-2500
Mailing Address - Fax:620-728-0823
Practice Address - Street 1:2101 NORTH WALDRON
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502
Practice Address - Country:US
Practice Address - Phone:620-669-2500
Practice Address - Fax:620-728-0823
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1500752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
426748Medicare ID - Type Unspecified
P34395Medicare UPIN