Provider Demographics
NPI:1578899456
Name:FERGUSON, KIMBERLY Y (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:Y
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:Y
Other - Last Name:TANNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:321C POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9306
Mailing Address - Country:US
Mailing Address - Phone:804-733-5591
Mailing Address - Fax:804-733-3506
Practice Address - Street 1:321C POPLAR DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9306
Practice Address - Country:US
Practice Address - Phone:804-733-5591
Practice Address - Fax:804-733-3506
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant