Provider Demographics
NPI:1043470115
Name:MACE-WEASE, KRISTEN L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:L
Last Name:MACE-WEASE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:L
Other - Last Name:MACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1700 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7529
Mailing Address - Country:US
Mailing Address - Phone:717-272-6621
Mailing Address - Fax:717-228-6045
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:717-228-6045
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053430363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA053430OtherLICENSE