Provider Demographics
NPI:1043622277
Name:CARTER, KRISTA N (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:N
Last Name:CARTER
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 1:401 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4264
Mailing Address - Country:US
Mailing Address - Phone:312-635-0973
Mailing Address - Fax:
Practice Address - Street 1:7068 S OUTER 364
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7757
Practice Address - Country:US
Practice Address - Phone:636-240-6100
Practice Address - Fax:636-240-1182
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001633A363A00000X
MO2015009297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015009297OtherLICENSE NO
MO2015009297OtherSTATE LICENSE
MO2015009297OtherLICENSE NO