Provider Demographics
NPI:1104392588
Name:KOHUTH, KRISTINA (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:KOHUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:ALYSE
Other - Last Name:MAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3712 GREENVILLE LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5616
Mailing Address - Country:US
Mailing Address - Phone:772-486-0807
Mailing Address - Fax:
Practice Address - Street 1:1402 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2235
Practice Address - Country:US
Practice Address - Phone:772-486-0807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant