Provider Demographics
NPI:1437186889
Name:KINNEBREW, KIMBERLY JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:KINNEBREW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12350 INDUSTRY WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-4301
Mailing Address - Country:US
Mailing Address - Phone:907-206-9114
Mailing Address - Fax:907-206-7009
Practice Address - Street 1:12350 INDUSTRY WAY STE 110
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-4301
Practice Address - Country:US
Practice Address - Phone:907-206-9114
Practice Address - Fax:907-206-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60953898363A00000X
AK408363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKP56059Medicare UPIN