Provider Demographics
NPI:1962601310
Name:CANTWELL-GAB, KIM R (ARNP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:CANTWELL-GAB
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MEDICAL CENTER DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4314
Mailing Address - Country:US
Mailing Address - Phone:541-732-7850
Mailing Address - Fax:
Practice Address - Street 1:1698 E MCANDREWS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5589
Practice Address - Country:US
Practice Address - Phone:541-732-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007760363L00000X
OR201503207NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9653080Medicaid
WAG8887604Medicare PIN