Provider Demographics
NPI:1427436393
Name:KIRKLEY, ARCHIE THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:ARCHIE
Middle Name:THOMAS
Last Name:KIRKLEY
Suffix:
Gender:M
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 1:125 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4770
Mailing Address - Country:US
Mailing Address - Phone:912-538-8484
Mailing Address - Fax:912-538-8665
Practice Address - Street 1:125 CHURCH ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4770
Practice Address - Country:US
Practice Address - Phone:912-538-8484
Practice Address - Fax:912-538-8665
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA007567OtherGEORGIA COMPOSITE MEDICAL BOARD