Provider Demographics
NPI:1316325053
Name:SLATER, KIMBERLY D (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:SLATER
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 1:1819 MARTINS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-5607
Mailing Address - Country:US
Mailing Address - Phone:304-543-3290
Mailing Address - Fax:304-984-0522
Practice Address - Street 1:5430 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2224
Practice Address - Country:US
Practice Address - Phone:304-925-3627
Practice Address - Fax:304-925-1163
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1119197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant