Provider Demographics
NPI:1275749053
Name:BRONDSTATER, KIRSTEN N (PA)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:N
Last Name:BRONDSTATER
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 1:1605 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4603
Mailing Address - Country:US
Mailing Address - Phone:407-975-0200
Mailing Address - Fax:407-975-0209
Practice Address - Street 1:1605 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4603
Practice Address - Country:US
Practice Address - Phone:407-975-0200
Practice Address - Fax:407-975-0209
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002279363A00000X
FL9107257363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00657230OtherMEDICARE RR
FLHM254ZMedicare PIN
VAMC10565Medicare PIN