Provider Demographics
NPI:1679682660
Name:KIM, CONNIE S (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:KIM
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 1:404 S SUTHERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5060
Mailing Address - Country:US
Mailing Address - Phone:704-291-9267
Mailing Address - Fax:704-225-0428
Practice Address - Street 1:404 S SUTHERLAND AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5060
Practice Address - Country:US
Practice Address - Phone:704-291-9267
Practice Address - Fax:704-225-0428
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2756086Medicare ID - Type Unspecified
NCP77557Medicare UPIN