Provider Demographics
NPI:1245272236
Name:KIMBALL, JOHN (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 HARDING DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:USC UNIVERSITY HOSPITAL
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-7400
Practice Address - Fax:323-442-7411
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3280367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN0532690Medicaid
CAWNA3280AMedicare ID - Type Unspecified
Q60935Medicare UPIN