Provider Demographics
NPI:1023037173
Name:ANDERSON, KRISTINE S (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:M
Other - Last Name:SANKOVITCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:1802 S MATTIS AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5923
Practice Address - Country:US
Practice Address - Phone:217-383-3260
Practice Address - Fax:217-383-4459
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004827363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP86005Medicare UPIN
IL6447860011Medicare NSC
P86005Medicare UPIN
ILIL3270443Medicare PIN