1083615876 NPI number — KIMBERLY DIANE MATTHEWS CHRISTOPHER CRNA

Table of content: KIMBERLY DIANE MATTHEWS CHRISTOPHER CRNA (NPI 1083615876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083615876 NPI number — KIMBERLY DIANE MATTHEWS CHRISTOPHER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTHEWS CHRISTOPHER
Provider First Name:
KIMBERLY
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHRISTOPHER
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083615876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 780
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26507-0780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 VAN VOORHIS RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-3587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-598-6216
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN-275195-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 37117 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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