Provider Demographics
NPI:1497912919
Name:HOWE, KIMBERLY JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JORDAN
Last Name:HOWE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 OLD NORCROSS RD
Mailing Address - Street 2:STE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3393
Mailing Address - Country:US
Mailing Address - Phone:770-339-1500
Mailing Address - Fax:770-995-6172
Practice Address - Street 1:748 OLD NORCROSS RD
Practice Address - Street 2:STE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3393
Practice Address - Country:US
Practice Address - Phone:770-339-1500
Practice Address - Fax:770-995-6172
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA772673258EMedicaid
GA202I973926Medicare PIN