Provider Demographics
NPI:1093763559
Name:PUTTS, KRISTY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:L
Last Name:PUTTS
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 1:1001 BLYTHE BLVD.
Mailing Address - Street 2:SUITE 300 - CARDIAC SURGERY:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5863
Mailing Address - Country:US
Mailing Address - Phone:704-373-0212
Mailing Address - Fax:704-372-1249
Practice Address - Street 1:1001 BLYTHE BLVD.
Practice Address - Street 2:SUITE 300 - CARDIAC SURGERY:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5863
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:704-372-1249
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00095363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0811PAMedicaid
NC8101666Medicaid
NC1093763559Medicaid
NCNC4535BMedicare PIN
NCP38016Medicare UPIN
NC2763916Medicare PIN
NCNC435AMedicare PIN
NC8101666Medicaid