Provider Demographics
NPI:1043634702
Name:RICHARDSON, KRISTEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:RICHARDSON
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 1:108 BELLE MEADE PT
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-3308
Mailing Address - Country:US
Mailing Address - Phone:601-992-7002
Mailing Address - Fax:
Practice Address - Street 1:108 BELLE MEADE PT
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3308
Practice Address - Country:US
Practice Address - Phone:601-992-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant