Provider Demographics
NPI:1174166714
Name:ESGATE, KIMBERLY ERIN (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ERIN
Last Name:ESGATE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:ESGATE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1970 RORY LN UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4388
Mailing Address - Country:US
Mailing Address - Phone:805-875-7883
Mailing Address - Fax:
Practice Address - Street 1:187 E WILBUR RD STE 100
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7925
Practice Address - Country:US
Practice Address - Phone:805-492-1015
Practice Address - Fax:805-492-2035
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-27
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA58862363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program