Provider Demographics
NPI:1902909872
Name:MATZEL, KIMBERLY ANN (PAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:MATZEL
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 1:2111 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605
Mailing Address - Country:US
Mailing Address - Phone:276-322-4661
Mailing Address - Fax:276-322-4663
Practice Address - Street 1:2111 COLLEGE AVE
Practice Address - Street 2:BLUEFIELD INTERNAL MEDICINE
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605
Practice Address - Country:US
Practice Address - Phone:276-322-4661
Practice Address - Fax:276-322-4663
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840635207R00000X
WV590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001209006Medicaid
VA007110459Medicaid
S22641Medicare UPIN
WVPA76521Medicare ID - Type Unspecified
WV0001209006Medicaid