Provider Demographics
NPI:1174809164
Name:PENASO, KIMBERLY (PA-C)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:PENASO
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 1:2350 W EL CAMINO REAL
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6201
Mailing Address - Country:US
Mailing Address - Phone:650-394-3546
Mailing Address - Fax:
Practice Address - Street 1:2907 CHANTICLEER AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1815
Practice Address - Country:US
Practice Address - Phone:650-934-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-23
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52672363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant