1922081744 NPI number — KIMBERLY WOODS SHIPPER PA-C

Table of content: KIMBERLY WOODS SHIPPER PA-C (NPI 1922081744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922081744 NPI number — KIMBERLY WOODS SHIPPER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIPPER
Provider First Name:
KIMBERLY
Provider Middle Name:
WOODS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODS
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922081744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9072
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77340-0018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-348-5039
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-291-4589
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA04565 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA04565 . This is a "PHYSICIAN ASSISTANT LICEN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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