Provider Demographics
NPI:1245293463
Name:KIMBALL, BEVERLY A (PA-C)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:ANN
Other - Last Name:FRYE-FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:1700 W STOUT ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-5000
Practice Address - Country:US
Practice Address - Phone:715-236-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8905207Q00000X
WI225-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN843159100Medicaid
WI41935200Medicaid
MN843159100Medicaid
WI41935200Medicaid