Provider Demographics
NPI:1760534341
Name:CAMPBELL, KIMBERLY THAXTON (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:THAXTON
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:THAXTON
Other - Last Name:GERNI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2601 LAKE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6688
Mailing Address - Country:US
Mailing Address - Phone:919-783-4888
Mailing Address - Fax:919-783-4887
Practice Address - Street 1:2601 LAKE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6688
Practice Address - Country:US
Practice Address - Phone:919-783-4888
Practice Address - Fax:919-783-4887
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2010-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103031363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2753082AMedicare ID - Type Unspecified
NCP26411Medicare UPIN