Provider Demographics
NPI:1033329750
Name:SMOL, KRISTEN LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNN
Last Name:SMOL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 16TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1205
Mailing Address - Country:US
Mailing Address - Phone:510-451-4270
Mailing Address - Fax:510-451-4285
Practice Address - Street 1:616 16TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1205
Practice Address - Country:US
Practice Address - Phone:510-563-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant