Provider Demographics
NPI:1598768046
Name:GANGWISH, KIMBERLEY F (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:F
Last Name:GANGWISH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N DIERS AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4984
Mailing Address - Country:US
Mailing Address - Phone:308-384-5400
Mailing Address - Fax:308-384-5201
Practice Address - Street 1:620 N DIERS AVE
Practice Address - Street 2:STE 200
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4984
Practice Address - Country:US
Practice Address - Phone:308-384-5400
Practice Address - Fax:308-384-5201
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE427363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47054564512Medicaid
NE089698Medicare ID - Type Unspecified
NE47054564512Medicaid