Healthcare Provider Details

I. General information

NPI: 1902315625
Provider Name (Legal Business Name): RANDY KIMERY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 OLEANDER DR STE 201
WILMINGTON NC
28403-4722
US

IV. Provider business mailing address

9 WALDEN RIDGE DR STE 10
ASHEVILLE NC
28803-8592
US

V. Phone/Fax

Practice location:
  • Phone: 833-365-7246
  • Fax:
Mailing address:
  • Phone: 833-365-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-10558
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC06610
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: