Healthcare Provider Details

I. General information

NPI: 1053405027
Provider Name (Legal Business Name): KIMBERLY B. FOGARTY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 M ST NW SUITE 205
WASHINGTON DC
20037-1404
US

IV. Provider business mailing address

2440 M ST NW SUITE 205
WASHINGTON DC
20037-1404
US

V. Phone/Fax

Practice location:
  • Phone: 202-955-0003
  • Fax: 866-457-0397
Mailing address:
  • Phone: 202-955-0003
  • Fax: 866-457-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110001588
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: