Provider Demographics
NPI:1063819944
Name:MCCAULEY, KRISTINA RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:RENEE
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:RENEE
Other - Last Name:BARRACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3020 CHILDREN'S WAY, MC 5024
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-966-8030
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDREN'S WAY, MC 5024
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-966-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant