Provider Demographics
NPI:1609151786
Name:MACINTIRE, KIMBERLY BETH (PAC)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:BETH
Last Name:MACINTIRE
Suffix:
Gender:F
Credentials:PAC
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Mailing Address - Street 1:256 FORT SANDERS WEST BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3355
Mailing Address - Country:US
Mailing Address - Phone:865-231-9481
Mailing Address - Fax:865-769-4501
Practice Address - Street 1:400 GOODYS LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-1900
Practice Address - Country:US
Practice Address - Phone:865-288-8327
Practice Address - Fax:865-288-5903
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV363A00000X
ALPA.892363A00000X
TN2091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I985153Medicare PIN