Provider Demographics
NPI:1093015448
Name:GASPERS, KRISTINA REGINA (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:REGINA
Last Name:GASPERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:REGINA
Other - Last Name:MALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:16519 S RTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-2606
Mailing Address - Country:US
Mailing Address - Phone:630-646-5020
Mailing Address - Fax:630-646-5025
Practice Address - Street 1:16519 S RTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-2606
Practice Address - Country:US
Practice Address - Phone:630-646-5020
Practice Address - Fax:630-646-5025
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01633203OtherBCBS GROUP
IL10115176OtherBCBS GROUP
IL01633203OtherBCBS GROUP
IL769380Medicare PIN
IL10115176OtherBCBS GROUP