Provider Demographics
NPI:1396052007
Name:THOMAS, KIMBERLY ELAINE (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ELAINE
Last Name:THOMAS
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 1:1275 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3476
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-205-6373
Practice Address - Street 1:3177 OCEAN VIEW BLVD
Practice Address - Street 2:OCEAN VIEW CHC
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-1432
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-205-6373
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16768363A00000X
PA16768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16768OtherLICENSE