Provider Demographics
NPI:1821320656
Name:JOHNSON, KIMBERLY SANDERS (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SANDERS
Last Name:JOHNSON
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:PO BOX 32569
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2569
Mailing Address - Country:US
Mailing Address - Phone:865-694-0062
Mailing Address - Fax:865-694-7907
Practice Address - Street 1:9430 PARK WEST BLVD
Practice Address - Street 2:# 130
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4200
Practice Address - Country:US
Practice Address - Phone:865-690-4861
Practice Address - Fax:865-560-8252
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTEMPORARY PERMIT363AS0400X
TNPA0000001820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I970670Medicare PIN
TN0677340001Medicare NSC