Provider Demographics
NPI:1750391462
Name:WALLACH, KIMBERLY S (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:WALLACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3191 STILLWATER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7143
Mailing Address - Country:US
Mailing Address - Phone:928-445-7085
Mailing Address - Fax:928-445-7095
Practice Address - Street 1:6496 E STATE ROUTE 69
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2920
Practice Address - Country:US
Practice Address - Phone:928-775-9007
Practice Address - Fax:928-775-9048
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5775363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750391462Medicare PIN