Provider Demographics
NPI:1477666576
Name:VETTER, KIMBERLY L (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:VETTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5100 PRAIRIE PKWY STE 302
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-8155
Mailing Address - Country:US
Mailing Address - Phone:319-277-1990
Mailing Address - Fax:319-222-2999
Practice Address - Street 1:5100 PRAIRIE PKWY STE 302
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-8155
Practice Address - Country:US
Practice Address - Phone:319-277-1990
Practice Address - Fax:319-222-2999
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0181867Medicaid
IA0181867Medicaid
IA17647Medicare ID - Type UnspecifiedMEDICARE