Provider Demographics
NPI:1952742660
Name:GORDON, KIMBERLY BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BETH
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SAM PERRY BLVD
Mailing Address - Street 2:TOMPKINS MARTIN MEDICAL PLAZA SUITE 221
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4467
Mailing Address - Country:US
Mailing Address - Phone:540-741-2855
Mailing Address - Fax:540-741-2868
Practice Address - Street 1:1101 SAM PERRY BLVD
Practice Address - Street 2:TOMPKINS MARTIN MEDICAL PLAZA SUITE 221
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4467
Practice Address - Country:US
Practice Address - Phone:540-741-2855
Practice Address - Fax:540-741-2868
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant