Provider Demographics
NPI:1447748413
Name:BISHOP, KIMBALL LAMAR (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBALL
Middle Name:LAMAR
Last Name:BISHOP
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5579 FM 132
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-7695
Mailing Address - Country:US
Mailing Address - Phone:936-545-7774
Mailing Address - Fax:
Practice Address - Street 1:5579 FM 132
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-7695
Practice Address - Country:US
Practice Address - Phone:936-545-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2060688225200000X
TX2060688225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2060688OtherPHYSICAL THERAPIST ASSISTANT