Provider Demographics
NPI:1821088600
Name:SHIBAYAMA, KIMBERLY JILL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JILL
Last Name:SHIBAYAMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:JILL
Other - Last Name:WOODLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 105132
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-5132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4230 HARDING RD
Practice Address - Street 2:SUITE 1000
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205-2013
Practice Address - Country:US
Practice Address - Phone:615-383-2693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1187363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3662762Medicare ID - Type Unspecified
TNQ27000Medicare UPIN