Provider Demographics
NPI:1952380859
Name:EVANS, KIMBERLY A (PA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:EVANS
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 1:3707 BRAMBLETON AVE SW
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:540-725-7800
Mailing Address - Fax:
Practice Address - Street 1:3707 BRAMBLETON AVE SW
Practice Address - Street 2:SUITE 2
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-725-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQMB1952380859Medicaid
VA1952380859Medicaid
VA018003C18Medicare PIN
VA1952380859Medicaid
VA005251K07Medicare PIN
VAQ21118Medicare UPIN
Q21118Medicare UPIN