Provider Demographics
NPI:1053405027
Name:FOGARTY, KIMBERLY B (PAC)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:B
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 M ST NW
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1404
Mailing Address - Country:US
Mailing Address - Phone:202-955-0003
Mailing Address - Fax:866-457-0397
Practice Address - Street 1:2440 M ST NW
Practice Address - Street 2:SUITE 205
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1404
Practice Address - Country:US
Practice Address - Phone:202-955-0003
Practice Address - Fax:866-457-0397
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001588363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC145453OtherLICENSE
VA0110001588OtherLICENSE
DCPA030663OtherLICENSE
DCPA030663OtherLICENSE