Provider Demographics
NPI:1023553096
Name:BULLOCK, KRISTINA LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNNE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3801 WAKE FOREST RD
Mailing Address - Street 2:STE 210
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6864
Mailing Address - Country:US
Mailing Address - Phone:919-562-9410
Mailing Address - Fax:919-562-2948
Practice Address - Street 1:115 KILDAIRE PARK DR STE 205
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8127
Practice Address - Country:US
Practice Address - Phone:919-787-7246
Practice Address - Fax:919-787-7247
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC219961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant