Provider Demographics
NPI:1245524776
Name:SHALL, KAMILLA A (PA)
Entity type:Individual
Prefix:MRS
First Name:KAMILLA
Middle Name:A
Last Name:SHALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KAMILLA
Other - Middle Name:
Other - Last Name:ABRAMOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:230 CLEARFIELD AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:757-321-3332
Practice Address - Street 1:160 KINGSLEY LN
Practice Address - Street 2:SUITE 400
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4600
Practice Address - Country:US
Practice Address - Phone:757-321-3383
Practice Address - Fax:757-321-3332
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV2842BMedicare PIN