Basic Information
| Provider Information | |||||||||
| NPI: | 1417902909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINKADE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8900 INDIAN CREEK PKWY | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662101554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136424900 | ||||||||
| FaxNumber: | 9133810979 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416286634 | ||||||||
| FaxNumber: | 9133810979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 058017 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3265819 | 05 | IA | MEDICAID |