Provider Demographics
NPI:1154348829
Name:KREIFELDT, KIMBERLY A (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:KREIFELDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 SPRING ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7965
Mailing Address - Country:US
Mailing Address - Phone:619-461-7277
Mailing Address - Fax:619-461-7278
Practice Address - Street 1:4215 SPRING ST
Practice Address - Street 2:SUITE 125
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7965
Practice Address - Country:US
Practice Address - Phone:619-461-7277
Practice Address - Fax:619-461-7278
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15049363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP02464Medicare UPIN