Provider Demographics
NPI:1669403895
Name:JOSEPH, KIMBERLY (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JOSEPH
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 1:700 ISLAND COTTAGE RD
Mailing Address - Street 2:EDNA TINA WILSON CENTER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-2312
Mailing Address - Country:US
Mailing Address - Phone:585-368-6100
Mailing Address - Fax:585-368-6133
Practice Address - Street 1:700 ISLAND COTTAGE RD
Practice Address - Street 2:EDNA TINA WILSON CENTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-2312
Practice Address - Country:US
Practice Address - Phone:585-368-6100
Practice Address - Fax:585-368-6133
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02734710Medicaid
S95742Medicare UPIN
NYBB8268 - GRP: 70008AMedicare PIN
NYPA0007- GRP: BA0017Medicare PIN