Provider Demographics
NPI:1942633318
Name:DIZON, KIMBERLY RUIZ (MHS, PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RUIZ
Last Name:DIZON
Suffix:
Gender:F
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:FLORES
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, CNIM
Mailing Address - Street 1:1530 E HAMMER LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3149
Mailing Address - Country:US
Mailing Address - Phone:099-543-2002
Mailing Address - Fax:
Practice Address - Street 1:1530 E HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210
Practice Address - Country:US
Practice Address - Phone:209-954-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant