Provider Demographics
NPI:1457518946
Name:EVANS, KIMBERLY ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7026
Mailing Address - Country:US
Mailing Address - Phone:530-543-5691
Mailing Address - Fax:530-542-2872
Practice Address - Street 1:1139 3RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3465
Practice Address - Country:US
Practice Address - Phone:530-543-5691
Practice Address - Fax:530-542-2872
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14825208600000X
CAA112322208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN