Provider Demographics
NPI:1376684514
Name:PIERSON, KIMBERLY D (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:PIERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:BOUTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3440 LOMITA BLVD
Mailing Address - Street 2:STE 442
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4801
Mailing Address - Country:US
Mailing Address - Phone:310-530-5451
Mailing Address - Fax:
Practice Address - Street 1:31625 DE PORTOLA RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2770
Practice Address - Country:US
Practice Address - Phone:951-501-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8875121Medicare PIN
WAQ51274Medicare UPIN