Provider Demographics
NPI:1619003928
Name:MOFFATT-BAZILE, KIM GENET (PNP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:GENET
Last Name:MOFFATT-BAZILE
Suffix:
Gender:F
Credentials:PNP
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Other - Credentials:
Mailing Address - Street 1:747 52ND ST
Mailing Address - Street 2:HEMO/ONCOLOGY DEPT
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1809
Mailing Address - Country:US
Mailing Address - Phone:510-428-3372
Mailing Address - Fax:510-597-7199
Practice Address - Street 1:3121 S. MARYLAND PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109
Practice Address - Country:US
Practice Address - Phone:702-732-1493
Practice Address - Fax:702-732-1080
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2019-05-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NVRN80724163WP0200X
CA8485363L00000X
NVAPRN001811163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics