Healthcare Provider Details

I. General information

NPI: 1336280015
Provider Name (Legal Business Name): MARTIN KIMBLE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WEEOT WAY
ARCATA CA
95521-4734
US

IV. Provider business mailing address

1600 WEEOT WAY
ARCATA CA
95521-4734
US

V. Phone/Fax

Practice location:
  • Phone: 707-825-5000
  • Fax: 707-825-6747
Mailing address:
  • Phone: 707-825-5000
  • Fax: 707-825-6747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number19051
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15217
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number527057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: