Provider Demographics
NPI:1164561056
Name:HAILE, KRISTE K (PA)
Entity Type:Individual
Prefix:
First Name:KRISTE
Middle Name:K
Last Name:HAILE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11970 N CENTRAL EXPY STE 210
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3784
Mailing Address - Country:US
Mailing Address - Phone:940-381-2003
Mailing Address - Fax:940-483-1221
Practice Address - Street 1:11970 N CENTRAL EXPY STE 210
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3784
Practice Address - Country:US
Practice Address - Phone:214-575-5885
Practice Address - Fax:907-785-4662
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00112363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C7878Medicare ID - Type UnspecifiedMEDICARE NUMBER
TXR59638Medicare UPIN