Provider Demographics
NPI:1376718841
Name:IDE, CHRISTINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:M
Last Name:IDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:M
Other - Last Name:MARCINOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57 BEAM LN STE 300
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2350
Practice Address - Country:US
Practice Address - Phone:540-213-2220
Practice Address - Fax:540-213-2225
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030506363AM0700X
VA0110-003111363A00000X
NC0010-02361363AM0700X
MDC0005333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical