Provider Demographics
NPI:1689902603
Name:WATSON NELSON, KIMBER KATHLEEN (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBER
Middle Name:KATHLEEN
Last Name:WATSON NELSON
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:395 W COUGAR BLVD STE 205
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3328
Practice Address - Country:US
Practice Address - Phone:801-357-1770
Practice Address - Fax:801-357-1779
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20714363A00000X
UT10106906-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant