Provider Demographics
NPI:1306113618
Name:FISK, KIMBERLY MARLENE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MARLENE
Last Name:FISK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CONLEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722-8709
Mailing Address - Country:US
Mailing Address - Phone:406-846-1320
Mailing Address - Fax:
Practice Address - Street 1:500 CONLEY LAKE RD
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-8709
Practice Address - Country:US
Practice Address - Phone:406-846-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant