Provider Demographics
NPI:1184687741
Name:CHRISTOPHERSON, KATHLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:CHRISTOPHERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30053
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89520-3053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 PRINGLE WAY
Practice Address - Street 2:STE. 301
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1464
Practice Address - Country:US
Practice Address - Phone:775-686-4300
Practice Address - Fax:775-686-4320
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6569208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
01WCHJA02Medicare ID - Type Unspecified
C94158Medicare UPIN