Provider Demographics
NPI:1740511096
Name:NEMATI, KIMBERLY J (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:NEMATI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:908 SCARBRO RD
Mailing Address - Street 2:PO BOX 337
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-8837
Mailing Address - Country:US
Mailing Address - Phone:304-574-3960
Mailing Address - Fax:304-574-2179
Practice Address - Street 1:221 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1413
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-574-2179
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV493363A00000X
WV01540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2034482Medicare PIN
WV2034481Medicare PIN