Provider Demographics
NPI:1023149101
Name:REISENAUER, KIMBERLY W (PA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:W
Last Name:REISENAUER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:S
Other - Last Name:WEISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:325 BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4167
Mailing Address - Country:US
Mailing Address - Phone:803-773-5227
Mailing Address - Fax:803-774-5400
Practice Address - Street 1:325 BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4167
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-774-5400
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0109PAMedicaid
SCP17947Medicare UPIN