Provider Demographics
NPI:1538291448
Name:MASTERS, KIM O (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:O
Last Name:MASTERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:190 PARKRIDGE DRIVE
Practice Address - Street 2:SUITE 250
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1747
Practice Address - Country:US
Practice Address - Phone:803-407-3857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN 856363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1354Medicaid
SCS886505738Medicare PIN
SCNP1354Medicaid