Provider Demographics
NPI:1811419393
Name:CRONSHAW, KIMBERLY (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CRONSHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7019 HARPS MILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3248
Mailing Address - Country:US
Mailing Address - Phone:919-850-1300
Mailing Address - Fax:919-850-0012
Practice Address - Street 1:7019 HARPS MILL RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3248
Practice Address - Country:US
Practice Address - Phone:919-850-1300
Practice Address - Fax:919-850-0012
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07178207R00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-07178OtherMEDICAL LICENSE
NCMC4367543OtherDEA NUMBER