Provider Demographics
NPI:1437748191
Name:KIMBERLEY-BRYANT, MAXWELL LAMBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:LAMBERT
Last Name:KIMBERLEY-BRYANT
Suffix:
Gender:M
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:PO BOX 511250
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7805
Mailing Address - Country:US
Mailing Address - Phone:510-929-1400
Mailing Address - Fax:510-929-1414
Practice Address - Street 1:1144 65TH ST STE F
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-1053
Practice Address - Country:US
Practice Address - Phone:510-929-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2442363A00000X
CA62817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant