Provider Demographics
NPI:1023214566
Name:WAACK, KIMBERLY JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:WAACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JOY
Other - Last Name:HARDWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 KILDAIRE PARK DR STE 301
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8144
Mailing Address - Country:US
Mailing Address - Phone:919-233-0410
Mailing Address - Fax:919-233-0872
Practice Address - Street 1:115 KILDAIRE PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8144
Practice Address - Country:US
Practice Address - Phone:919-233-0410
Practice Address - Fax:919-233-0872
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant