Provider Demographics
NPI:1669270310
Name:FUSSELMAN, KIMBERLY (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FUSSELMAN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2317 DIETZ FARM RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3117
Mailing Address - Country:US
Mailing Address - Phone:505-715-0008
Mailing Address - Fax:
Practice Address - Street 1:490A W ZIA RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6996
Practice Address - Country:US
Practice Address - Phone:505-913-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2025-0024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant