Provider Demographics
NPI:1417048356
Name:GREENWOOD, KIM ANDERSON (PNP, MS)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANDERSON
Last Name:GREENWOOD
Suffix:
Gender:M
Credentials:PNP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 N ARROYO BLVD
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2644
Mailing Address - Country:US
Mailing Address - Phone:520-287-4713
Mailing Address - Fax:520-287-9794
Practice Address - Street 1:590 S OCOTILLO AVE
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6405
Practice Address - Country:US
Practice Address - Phone:520-586-7080
Practice Address - Fax:520-586-3163
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPNPAP0073363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ488462OtherAHCCCS #
AZP00996Medicare UPIN
AZ78591Medicare ID - Type UnspecifiedMEDICARE