Provider Demographics
NPI:1114165479
Name:BARTH, KRISTIN PATRICIA (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:PATRICIA
Last Name:BARTH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-293-9590
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:135 MARIGOLD LN S
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-9386
Practice Address - Country:US
Practice Address - Phone:608-498-0375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-25
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007424367500000X
VA0001237783367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1114165479Medicaid