Provider Demographics
NPI:1902315625
Name:KIMERY, RANDY (PA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:KIMERY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WALDEN RIDGE DR STE 10
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-8592
Mailing Address - Country:US
Mailing Address - Phone:833-365-7246
Mailing Address - Fax:
Practice Address - Street 1:5710 OLEANDER DR STE 201
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4722
Practice Address - Country:US
Practice Address - Phone:833-365-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06610363AM0700X
NC0010-10558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical