Provider Demographics
NPI:1174964845
Name:KIM, KATIE RUBLE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:RUBLE
Last Name:KIM
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-9027
Mailing Address - Country:US
Mailing Address - Phone:515-961-3700
Mailing Address - Fax:
Practice Address - Street 1:301 E HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-9027
Practice Address - Country:US
Practice Address - Phone:515-961-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP01329951OtherRR MEDICARE
IA719260585Medicare PIN