Provider Demographics
NPI:1396359634
Name:BAUMGARDNER, KIM PATRICK
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:PATRICK
Last Name:BAUMGARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 HWY. 95A NORTH
Mailing Address - Street 2:
Mailing Address - City:FERNLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89408
Mailing Address - Country:US
Mailing Address - Phone:775-835-6427
Mailing Address - Fax:775-835-6158
Practice Address - Street 1:1280 HWY. 95A NORTH
Practice Address - Street 2:
Practice Address - City:FERNLEY
Practice Address - State:NV
Practice Address - Zip Code:89408
Practice Address - Country:US
Practice Address - Phone:775-835-6427
Practice Address - Fax:775-835-6158
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist