Provider Demographics
NPI:1336280015
Name:KIMBLE, MARTIN (PA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WEEOT WAY
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4734
Mailing Address - Country:US
Mailing Address - Phone:707-825-5000
Mailing Address - Fax:707-825-6747
Practice Address - Street 1:1600 WEEOT WAY
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4734
Practice Address - Country:US
Practice Address - Phone:707-825-5000
Practice Address - Fax:707-825-6747
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15217363L00000X
CA527057163W00000X
CA19051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABZ134ZMedicare PIN