Provider Demographics
NPI:1629702733
Name:FERGUSON, KIMBERLY NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:FERGUSON
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 1:875 AAA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-3624
Mailing Address - Country:US
Mailing Address - Phone:302-918-6400
Mailing Address - Fax:302-543-6002
Practice Address - Street 1:875 AAA BLVD STE C
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3624
Practice Address - Country:US
Practice Address - Phone:302-918-6400
Practice Address - Fax:302-543-6002
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011757363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical