Provider Demographics
NPI:1386626158
Name:LATAL, KRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:LATAL
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 1:12250 E ILIFF AVE
Mailing Address - Street 2:#300
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-6318
Mailing Address - Country:US
Mailing Address - Phone:303-306-4321
Mailing Address - Fax:720-524-1551
Practice Address - Street 1:12250 E ILIFF AVE
Practice Address - Street 2:#300
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-6318
Practice Address - Country:US
Practice Address - Phone:303-306-4321
Practice Address - Fax:720-524-1551
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93878087Medicaid
COCOA104589Medicare PIN
CO93878087Medicaid
CO93878087Medicaid