Basic Information
| Provider Information | |||||||||
| NPI: | 1194832006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HISSONG | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 WATT AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958213600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164816800 | ||||||||
| FaxNumber: | 9164811881 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 WATT AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958213600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164816800 | ||||||||
| FaxNumber: | 9164811881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 185262-1205 | UT | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | C139617 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 107005891101 | 01 | UT | IHC | OTHER | 36403 | 01 | UT | PEHP | OTHER | 416939 | 01 | UT | DESERET MUTUAL | OTHER | 09300 | 01 | CA | VALLEY CHILDRENS HEALTHCARE | OTHER | PR00880 | 01 | UT | MOLINA | OTHER | 2403 | 01 | UT | HEALTHY U | OTHER | 002084559 | 01 | UT | FIRST HEALTH | OTHER | 870280408HI1 | 01 | UT | EDUCATORS MUTUAL | OTHER | 2000040 | 01 | UT | UNITED HEALTHCARE | OTHER | QM0000049524 | 01 | UT | ALTIUS | OTHER | 002966900 | 05 | ID | MEDICAID | 111000400 | 05 | WY | MEDICAID | 401765 | 05 | MT | MEDICAID |