Provider Demographics
NPI:1871569855
Name:GRANT, KIMBERLY GILLIAM (PA-C)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:GILLIAM
Last Name:GRANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6107 N 1ST ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5460
Mailing Address - Country:US
Mailing Address - Phone:559-432-4963
Mailing Address - Fax:
Practice Address - Street 1:6107 N 1ST ST STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5460
Practice Address - Country:US
Practice Address - Phone:559-432-4963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA642363AM0700X
FL9109580363AM0700X
SCTL1232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0576APAMedicaid
SC0576APAMedicaid