Provider Demographics
NPI:1417080052
Name:DIEHL, KRISTI JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:JO
Last Name:DIEHL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:JO
Other - Last Name:GOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:16441 CYAN CT
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-4601
Mailing Address - Country:US
Mailing Address - Phone:909-393-8082
Mailing Address - Fax:909-606-9599
Practice Address - Street 1:15361 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-7608
Practice Address - Country:US
Practice Address - Phone:909-393-7171
Practice Address - Fax:909-393-7676
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18019363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical