Provider Demographics
NPI:1689009201
Name:KIMBALL, PETER (PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
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 1:4500 SAN PABLO RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1865
Mailing Address - Country:US
Mailing Address - Phone:904-953-2000
Mailing Address - Fax:
Practice Address - Street 1:2401 MONUMENT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2520
Practice Address - Country:US
Practice Address - Phone:904-642-0337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112110363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant