Provider Demographics
NPI:1326271412
Name:MYERS, KRISTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:PA-C
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 400
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-7048
Mailing Address - Country:US
Mailing Address - Phone:203-284-2800
Mailing Address - Fax:203-294-8734
Practice Address - Street 1:896 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2912
Practice Address - Country:US
Practice Address - Phone:860-788-3632
Practice Address - Fax:860-788-2085
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CT002320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008031383Medicaid