Provider Demographics
NPI:1962857383
Name:KIMBERLY J. SARGENT PA-C, PLLC
Entity Type:Organization
Organization Name:KIMBERLY J. SARGENT PA-C, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:SARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:928-856-2208
Mailing Address - Street 1:711 W ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-5301
Mailing Address - Country:US
Mailing Address - Phone:928-856-2208
Mailing Address - Fax:
Practice Address - Street 1:711 W ASPEN AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-5301
Practice Address - Country:US
Practice Address - Phone:928-856-2208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#2555363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
434649Medicare PIN
AZP588000512Medicare UPIN