Provider Demographics
NPI:1679902803
Name:RENO, KIMBERLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:RENO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4060 4TH AVE. #700
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-299-8500
Mailing Address - Fax:619-299-3370
Practice Address - Street 1:4060 4TH AVE #700
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-299-8500
Practice Address - Fax:619-299-3370
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60679363A00000X
GA007055363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003141282AMedicaid
GA003141282BMedicaid
GA003141282CMedicaid
GAP01264041OtherRAILROAD MEDICARE
GA202I973732Medicare PIN
GA003141282AMedicaid