Provider Demographics
NPI:1760691026
Name:DIMOCK, KIMBERLY A (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:DIMOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1080 S VAN DYKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9635
Mailing Address - Country:US
Mailing Address - Phone:989-269-6048
Mailing Address - Fax:989-269-6174
Practice Address - Street 1:1080 S VAN DYKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9635
Practice Address - Country:US
Practice Address - Phone:989-269-6048
Practice Address - Fax:989-269-6174
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3528363A00000X
MI5601005549363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant