Provider Demographics
NPI:1235603259
Name:WAKS, KIMBERLY JOY (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JOY
Last Name:WAKS
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 1:2800 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-382-2350
Mailing Address - Fax:475-210-3025
Practice Address - Street 1:2800 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606
Practice Address - Country:US
Practice Address - Phone:203-382-2350
Practice Address - Fax:475-210-3025
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5498363A00000X
VA0110-007506363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program