Provider Demographics
NPI:1689902603
Name:WATSON NELSON, KIMBER KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBER
Middle Name:KATHLEEN
Last Name:WATSON NELSON
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 1:17777 CENTER COURT DR N
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-8567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17777 CENTER COURT DR N
Practice Address - Street 2:SUITE 400
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-8567
Practice Address - Country:US
Practice Address - Phone:562-229-9452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant