Provider Demographics
NPI:1073916045
Name:LILLY, KRISTIN L (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:LILLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:L
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST FL 2
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-243-1000
Practice Address - Fax:434-244-7551
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05584363AS0400X
VA0110005573363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical