Provider Demographics
NPI:1114964558
Name:CONWAY, KRISTI LINN (DPM)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:LINN
Last Name:CONWAY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4887
Mailing Address - Country:US
Mailing Address - Phone:813-685-3668
Mailing Address - Fax:813-685-5430
Practice Address - Street 1:1149 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-0000
Practice Address - Country:US
Practice Address - Phone:813-685-3668
Practice Address - Fax:813-685-5430
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2913213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340208800Medicaid
FL340208800Medicaid
FLP00637238Medicare PIN
FL0727650001Medicare NSC
FLU86854Medicare UPIN