Provider Demographics
NPI:1285395905
Name:DOCTOR, KIMBERLY SAMANTHA (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SAMANTHA
Last Name:DOCTOR
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 1:2859 VIRGINIA BEACH BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7613
Mailing Address - Country:US
Mailing Address - Phone:757-772-1623
Mailing Address - Fax:
Practice Address - Street 1:2859 VIRGINIA BEACH BLVD STE 105
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7613
Practice Address - Country:US
Practice Address - Phone:757-772-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008725363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant