Provider Demographics
NPI:1871686519
Name:KIMBERLING, CODY J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:J
Last Name:KIMBERLING
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 1:601 WEST LEOTA STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6598
Mailing Address - Country:US
Mailing Address - Phone:308-696-8000
Mailing Address - Fax:
Practice Address - Street 1:601 WEST LEOTA STREET
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6598
Practice Address - Country:US
Practice Address - Phone:308-696-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47066229001Medicaid
NE47066229001Medicaid
NE273275Medicare PIN