Provider Demographics
NPI:1962057166
Name:HANNERS, KIMBERLY JEAN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:JEAN
Last Name:HANNERS
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KIMMI
Other - Middle Name:JEAN
Other - Last Name:HANNERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:9661 E TAHOE CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2192
Mailing Address - Country:US
Mailing Address - Phone:479-276-0796
Mailing Address - Fax:
Practice Address - Street 1:1066 N POWER RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5709
Practice Address - Country:US
Practice Address - Phone:480-807-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT141908363A00000X
PAMA062451363A00000X
AZ11022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant