Provider Demographics
NPI:1306916739
Name:SMITH, KIMBERLY RENEE (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:MEREDITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4101 TECHNOLOGY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-8548
Mailing Address - Country:US
Mailing Address - Phone:812-941-4500
Mailing Address - Fax:
Practice Address - Street 1:4101 TECHNOLOGY AVE
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-8548
Practice Address - Country:US
Practice Address - Phone:812-941-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000921363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00924294OtherRAILROAD MEDICARE PTAN
INM400014945Medicare PIN