Provider Demographics
NPI:1912192386
Name:KIRBOW, WILLIAM LYNN (HIS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LYNN
Last Name:KIRBOW
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:612-351-1529
Mailing Address - Fax:952-285-3980
Practice Address - Street 1:3272 SHERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3564
Practice Address - Country:US
Practice Address - Phone:325-949-9993
Practice Address - Fax:325-947-0277
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX237600000X
TX50505237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177930801Medicaid