Provider Demographics
NPI:1891829560
Name:UNDERWOOD, KIMBERLY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 NILES CORTLAND RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1055
Mailing Address - Country:US
Mailing Address - Phone:330-841-4032
Mailing Address - Fax:330-841-4381
Practice Address - Street 1:1934 NILES CORTLAND RD NE STE B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1055
Practice Address - Country:US
Practice Address - Phone:330-841-4032
Practice Address - Fax:330-841-4381
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084823Medicaid
OH0084823Medicaid