Provider Demographics
NPI:1346243466
Name:KASOW WICHLAN, KIMBERLY ANNE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:KASOW WICHLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 W FRANKLIN ST
Mailing Address - Street 2:SUITE #600
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-2539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-0001
Practice Address - Country:US
Practice Address - Phone:919-966-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-002692080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64068661Medicaid
AR150073003Medicaid
KS200377100AMedicaid
OR274915Medicaid
VA010173256Medicaid
IA0585364Medicaid
MS06924205Medicaid
MO209244102Medicaid
WI82556500Medicaid
AL009929575Medicaid
MI114677787Medicaid
TN5440442Medicaid
OK200014510AMedicaid
IN200449440AMedicaid
TX176189201Medicaid
ME422400000Medicaid
ME422400000Medicaid