Provider Demographics
NPI:1437892247
Name:KIMBLER, BRENT EARL (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:EARL
Last Name:KIMBLER
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 1:13200 W HEIDEN CIR UNIT 2409
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-1062
Mailing Address - Country:US
Mailing Address - Phone:585-435-8263
Mailing Address - Fax:
Practice Address - Street 1:789 WASHINGTON ST W
Practice Address - Street 2:
Practice Address - City:VALE
Practice Address - State:OR
Practice Address - Zip Code:97918-1147
Practice Address - Country:US
Practice Address - Phone:541-473-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant