Healthcare Provider Details

I. General information

NPI: 1538248018
Provider Name (Legal Business Name): KIMBERLY LOUISE HANKS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY LOUISE HANKS P.A.

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

500 5TH ST
BROOKINGS OR
97415-9702
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-3000
  • Fax: 541-412-2081
Mailing address:
  • Phone: 707-382-2921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15015
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA165753
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: