NPIMap

Individual provider Active NPI

Kimura Garcia Chermez'S Jacobs, PA-C

  • Physician Assistant
  • Winston Salem, NC
National Provider Identifier
1053949354
Registry record updated Mar 26, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0010-13855 Issued in NC
Practice address
Medical Center Blvd
Winston Salem, NC 27157-0001
Phone
(336) 716-2255
Fax
(336) 716-3202
NPI assigned
Mar 31, 2020
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 26, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgical Physician Assistant 363AS0400X PA9116654 FL
Physician Assistant 363A00000X 0010-13855 NC Primary

Addresses

Primary practice location

Medical Center Blvd
Winston Salem, NC 27157-0001

Mailing address

Medical Center Blvd
Winston Salem, NC 27157-0001
Phone (336) 716-2255

Other practice location 1

1350 Hickory St Ste 102
Melbourne, FL 32901-3224
Phone (321) 434-3455

Other identifiers 2

IdentifierTypeStateIssuer
116025800MedicaidFL
P1621OtherFLMEDICARE HF

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20240229004414 NC Practitioner - Physician Assistant 5890189286 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2021
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Wake Forest University Health SciencesGroup PAC ID 4486564952, 2,633 clinicians

Practice addresses (Care Compare)

601 N Elm St
High Point, NC 27262-4331
Phone (336) 716-2734

Medical Ctr Blvd
Winston Salem, NC 27157-0001
Phone (336) 716-2734

Hospital & facility affiliations

  • North Carolina Baptist Hospital Hospital, Winston-Salem, NC, CCN 340047
  • High Point Regional Health System Hospital, High Point, NC, CCN 340004

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
PA9116654FLMDSurgical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Wake Forest University Health Sciences CurrentSince Jan 22, 2024 Accepting new patients

Locations

Medical Ctr Blvd
Winston Salem, NC 27157
Phone (336) 713-2697

Interoperability endpoints

  • Direct secure messaging: kjacobs2856377@carolinashealthcaresystem.direct-ci.com

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1585612800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1711411200000",
    "number": "1053949354",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "MEDICAL CENTER BLVD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271570001",
            "telephone_number": "336-716-2255",
            "fax_number": "336-716-3202"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "MEDICAL CENTER BLVD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271570001",
            "telephone_number": "336-716-2255",
            "fax_number": "336-716-3202"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1350 Hickory St Ste 102",
            "address_purpose": "LOCATION",
            "city": "Melbourne",
            "state": "FL",
            "postal_code": "329013224",
            "country_code": "US",
            "telephone_number": "321-434-3455",
            "fax_number": "321-434-3456",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACOBS",
        "first_name": "KIMURA",
        "middle_name": "GARCIA CHERMEZ'S",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-03-31",
        "last_updated": "2024-03-26",
        "certification_date": "2024-03-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "FL",
            "license": "PA9116654",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-13855",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "116025800",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE HF",
            "identifier": "P1621",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Winston Salem, NC

Sources for this page

Verify at the official NPI Registry.