Provider Demographics
NPI:1043220320
Name:ANNIS, KIM A (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:ANNIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1211 21ST AVE S
Practice Address - Street 2:220 MEDICAL ARTS BUILDING
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-2702
Practice Address - Country:US
Practice Address - Phone:615-322-0128
Practice Address - Fax:615-936-6977
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN2346363AM0700X, 363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ003409Medicaid
KY95000972Medicaid