Provider Demographics
NPI:1841380235
Name:KIMBALL, RUSSELL B (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:B
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 1:31 JOHNSON STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04359
Mailing Address - Country:US
Mailing Address - Phone:207-512-2318
Mailing Address - Fax:
Practice Address - Street 1:250 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04333-0011
Practice Address - Country:US
Practice Address - Phone:207-624-4657
Practice Address - Fax:207-287-6123
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES98133Medicare UPIN