Provider Demographics
NPI:1447355334
Name:THOMAS, KIMBERLY LAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LAYNE
Last Name:THOMAS
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 1:1301 MEDICAL DR
Mailing Address - Street 2:P.O. BOX 87488
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4425
Mailing Address - Country:US
Mailing Address - Phone:910-486-5700
Mailing Address - Fax:910-486-5950
Practice Address - Street 1:1301 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4425
Practice Address - Country:US
Practice Address - Phone:910-486-5700
Practice Address - Fax:910-486-5950
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX334009301Medicaid
2761808AMedicare ID - Type Unspecified
TX334009301Medicaid
Q19298Medicare UPIN