Provider Demographics
NPI:1184338550
Name:KIMBALL, KOBY
Entity type:Individual
Prefix:
First Name:KOBY
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 CLIPPER RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-8010
Mailing Address - Country:US
Mailing Address - Phone:360-713-8586
Mailing Address - Fax:
Practice Address - Street 1:420 CLIPPER RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-8010
Practice Address - Country:US
Practice Address - Phone:360-713-8586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant