Provider Demographics
NPI:1528167251
Name:BELKE, KIMBERLY S (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:BELKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 RIVERSIDE DR.
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2732
Mailing Address - Country:US
Mailing Address - Phone:607-798-9356
Mailing Address - Fax:607-797-1707
Practice Address - Street 1:240 RIVERSIDE DR.
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2732
Practice Address - Country:US
Practice Address - Phone:607-798-9356
Practice Address - Fax:607-797-1707
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02720712Medicaid
NYPA1215Medicare ID - Type Unspecified
NY02720712Medicaid