Provider Demographics
NPI:1619974623
Name:KNOX, KIMBERLEE J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEE
Middle Name:J
Last Name:KNOX
Suffix:
Gender:F
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 1:3307 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5703
Mailing Address - Country:US
Mailing Address - Phone:619-347-5771
Mailing Address - Fax:
Practice Address - Street 1:3307 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5703
Practice Address - Country:US
Practice Address - Phone:619-347-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15400363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
321250010Medicare ID - Type Unspecified
P43261Medicare UPIN