Provider Demographics
NPI:1043651342
Name:KAISER, KRISTIN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:KAISER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:VANDERLAAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:19465 DEERFIELD AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-1707
Mailing Address - Country:US
Mailing Address - Phone:037-236-5687
Mailing Address - Fax:
Practice Address - Street 1:19465 DEERFIELD AVE STE 408
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-1707
Practice Address - Country:US
Practice Address - Phone:703-723-6568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA PA60394964363A00000X
VA0110005057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0317004OtherLNI
WA0317004OtherLNI