Provider Demographics
NPI:1912152380
Name:MADORSKY, KIMBERLY DENNISE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DENNISE
Last Name:MADORSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DENNISE
Other - Last Name:HAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE
Mailing Address - Street 1:1855 W REDLANDS BLVD
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3145
Mailing Address - Country:US
Mailing Address - Phone:909-890-0407
Mailing Address - Fax:909-890-4597
Practice Address - Street 1:17577 ARROW BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-4011
Practice Address - Country:US
Practice Address - Phone:909-823-4454
Practice Address - Fax:909-823-6918
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant