Provider Demographics
NPI:1598767204
Name:FLETCHER, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:SCOGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
Mailing Address - Street 2:393 E WALNUT ST
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:3100 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0436
Practice Address - Country:US
Practice Address - Phone:702-255-5025
Practice Address - Fax:702-255-5015
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10729207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502989Medicaid
NV39000Medicare ID - Type UnspecifiedNORIDIAN