Provider Demographics
NPI: | 1174827893 |
---|---|
Name: | CONNOR, KIMBERLY ELAINE (PA-C, CLE) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | KIMBERLY |
Middle Name: | ELAINE |
Last Name: | CONNOR |
Suffix: | |
Gender: | F |
Credentials: | PA-C, CLE |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1247 SUNCREST TOWN CENTRE DR |
Mailing Address - Street 2: | |
Mailing Address - City: | MORGANTOWN |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 26505-1876 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 304-599-8000 |
Mailing Address - Fax: | 304-599-8003 |
Practice Address - Street 1: | 110 SIMS CIRCLE |
Practice Address - Street 2: | |
Practice Address - City: | TRIADELPHIA |
Practice Address - State: | WV |
Practice Address - Zip Code: | 26059-1154 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-599-8000 |
Practice Address - Fax: | 304-599-8003 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-01-10 |
Last Update Date: | 2021-02-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
L-41918 | 174N00000X | |
WV | 349 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 174N00000X | Other Service Providers | Lactation Consultant, Non-RN |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WV | 1174827893 | Medicaid | |
OH | 018811 | Medicaid |