Provider Demographics
NPI:1295879963
Name:MCFADDEN, KIM R (PA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:MCFADDEN
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 7
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141-0007
Mailing Address - Country:US
Mailing Address - Phone:804-932-1005
Mailing Address - Fax:804-932-9860
Practice Address - Street 1:9010 POCAHONTAS TRAIL
Practice Address - Street 2:
Practice Address - City:PROVIDENCE FORGE
Practice Address - State:VA
Practice Address - Zip Code:23140
Practice Address - Country:US
Practice Address - Phone:804-966-5208
Practice Address - Fax:804-966-9712
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA014704V21Medicare PIN
VA014706V20Medicare PIN
VA014705V01Medicare PIN
VA015824V68Medicare PIN