Provider Demographics
NPI:1508985144
Name:THOMPSON-TUCKER, KIMBERLY LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEA
Last Name:THOMPSON-TUCKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:L
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1412 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3314
Mailing Address - Country:US
Mailing Address - Phone:252-623-2000
Mailing Address - Fax:877-559-4667
Practice Address - Street 1:1412 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3314
Practice Address - Country:US
Practice Address - Phone:252-623-2000
Practice Address - Fax:877-559-4667
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC102890OtherSTATE LICENSE NUMBER