Provider Demographics
NPI:1386630689
Name:FERGUSON, KRISTIN (PT)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 EL CAMINO AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4938
Mailing Address - Country:US
Mailing Address - Phone:916-487-3473
Mailing Address - Fax:916-487-3483
Practice Address - Street 1:4737 EL CAMINO AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4938
Practice Address - Country:US
Practice Address - Phone:916-487-3473
Practice Address - Fax:916-487-3483
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04666ZOtherGROUP BS PROV #
CAZZZ314823Medicare ID - Type UnspecifiedGROUP PROV #
CAOPT249720Medicare ID - Type UnspecifiedINDIVIDUAL PROV#