Healthcare Provider Details

I. General information

NPI: 1851609424
Provider Name (Legal Business Name): KIMBERLY ANN CARTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ANN CASPER PA-C

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 S 48TH ST STE 161
PHOENIX AZ
85044-9139
US

IV. Provider business mailing address

3020 E CAMELBACK RD STE 301
PHOENIX AZ
85016-4418
US

V. Phone/Fax

Practice location:
  • Phone: 602-633-4493
  • Fax: 602-716-9656
Mailing address:
  • Phone: 602-261-9100
  • Fax: 602-264-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA055465
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4719
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: