Provider Demographics
NPI:1588749964
Name:GATES, KIMBERLY J (PA-C)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:GATES
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 1:1404 N 189TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4486
Mailing Address - Country:US
Mailing Address - Phone:402-650-5554
Mailing Address - Fax:
Practice Address - Street 1:10862 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2609
Practice Address - Country:US
Practice Address - Phone:402-671-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38529OtherBCBS OF NEBRASKA
NES74355Medicare UPIN
NE275219Medicare ID - Type Unspecified