Provider Demographics
NPI:1275705311
Name:SUNG, KRISTIN ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:SUNG
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 NE GATEWAY CT NE
Practice Address - Street 2:STE 204
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2414
Practice Address - Country:US
Practice Address - Phone:704-403-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06219363A00000X
IN10001260A363AS0400X
NC001006219363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400066126Medicare PIN
MA0005467Medicare PIN