Healthcare Provider Details

I. General information

NPI: 1023214566
Provider Name (Legal Business Name): KIMBERLY JOY WAACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY JOY HARDWICK

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 JUAN TABO BLVD NE STE B
ALBUQUERQUE NM
87112-3303
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-5180
  • Fax: 505-702-8171
Mailing address:
  • Phone: 877-498-4490
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2026-0045
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00955
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: