Provider Demographics
NPI:1376875872
Name:OPITZ, KIMBERLY M (MPA, PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:OPITZ
Suffix:
Gender:F
Credentials:MPA, PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:ACERES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPA, PA-C
Mailing Address - Street 1:PO BOX 2059
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3328
Mailing Address - Country:US
Mailing Address - Phone:707-254-7117
Mailing Address - Fax:707-265-6435
Practice Address - Street 1:3273 CLAREMONT WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3328
Practice Address - Country:US
Practice Address - Phone:707-254-7117
Practice Address - Fax:707-265-6435
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102820Medicaid
ZZZ31151ZMedicare PIN