Healthcare Provider Details

I. General information

NPI: 1316325053
Provider Name (Legal Business Name): KIMBERLY D SLATER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 MACCORKLE AVE SE
CHARLESTON WV
25304-2224
US

IV. Provider business mailing address

1819 MARTINS BRANCH RD
CHARLESTON WV
25312-5607
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-3627
  • Fax: 304-925-1163
Mailing address:
  • Phone: 304-543-3290
  • Fax: 304-984-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1119197
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: