Healthcare Provider Details

I. General information

NPI: 1114142494
Provider Name (Legal Business Name): KIMIKO LYNNE ISHIBASHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 LAKESIDE DRIVE
RENO NV
89509
US

IV. Provider business mailing address

3725 LAKESIDE DRIVE
RENO NV
89509
US

V. Phone/Fax

Practice location:
  • Phone: 775-737-4707
  • Fax: 877-548-4385
Mailing address:
  • Phone: 775-737-4707
  • Fax: 877-548-4385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12595
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: