Healthcare Provider Details

I. General information

NPI: 1053374074
Provider Name (Legal Business Name): KATHRYN MARI LIN KINCEL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43658 STATE HIGHWAY 299 E
FALL RIVER MILLS CA
96028-9819
US

IV. Provider business mailing address

621 E FOSTER AVE
COEUR D ALENE ID
83814-3048
US

V. Phone/Fax

Practice location:
  • Phone: 530-999-9020
  • Fax:
Mailing address:
  • Phone: 208-967-2597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number15892
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004548
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: