Provider Demographics
NPI:1790733830
Name:GIPSON, KIMBERLEY WOLOSHIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:WOLOSHIN
Last Name:GIPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:KOONS
Other - Last Name:WOLOSHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 EMANCIPATION DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:757-227-9967
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-227-9967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1790733830Medicaid
VA1790733830Medicaid
VAI63161Medicare UPIN