Basic Information
| Provider Information | |||||||||
| NPI: | 1104328699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUNDICK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | PA-C, MMSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1270 5TH AVE APT 10A | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100293425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302341024 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1275 YORK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100656007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126392000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 10/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA11832 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 023714-01 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 382407001 | 05 | TX | MEDICAID | 382407002 | 05 | TX | MEDICAID |