Provider Demographics
NPI:1881881985
Name:SCOTT, KIMBERLY BASILLA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:BASILLA
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KIMBERLY
Other - Middle Name:BASILLA
Other - Last Name:COVINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1505 N. EDGEMONT STREET
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027
Mailing Address - Country:US
Mailing Address - Phone:323-783-4704
Mailing Address - Fax:323-783-8677
Practice Address - Street 1:1505 N EDGEMONT ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5209
Practice Address - Country:US
Practice Address - Phone:323-783-4703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19376363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant