Healthcare Provider Details

I. General information

NPI: 1023149101
Provider Name (Legal Business Name): KIMBERLY W REISENAUER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY S WEISS PA

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 BROAD ST SUITE 100
SUMTER SC
29150-4167
US

IV. Provider business mailing address

325 BROAD ST SUITE 100
SUMTER SC
29150-4167
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax: 803-774-5400
Mailing address:
  • Phone: 803-773-5227
  • Fax: 803-774-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number638
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: