Provider Demographics
NPI:1598780710
Name:GENTRY, KIMBERLY N (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PA-C
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 3710
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-3710
Mailing Address - Country:US
Mailing Address - Phone:828-324-9550
Mailing Address - Fax:828-324-4154
Practice Address - Street 1:2406 CENTURY PL SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4031
Practice Address - Country:US
Practice Address - Phone:828-324-9550
Practice Address - Fax:828-324-4154
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-00481OtherLICENSE
Q71039Medicare UPIN
2766638Medicare PIN