Provider Demographics
NPI:1396405411
Name:POPELKA, KRISTINE (MS ATC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:POPELKA
Suffix:
Gender:F
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SHELDON PL APT 3
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6079
Mailing Address - Country:US
Mailing Address - Phone:207-616-9898
Mailing Address - Fax:
Practice Address - Street 1:4000 MAYFLOWER HL
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-8840
Practice Address - Country:US
Practice Address - Phone:207-859-4490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT717207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEAT717OtherAT STATE LICENSE