Provider Demographics
NPI:1437175650
Name:LASTER, KRISTIN CLICKETT (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:CLICKETT
Last Name:LASTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:M
Other - Last Name:CLICKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:155 ZEPHYR MOUNTAIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:STATE ROAD
Mailing Address - State:NC
Mailing Address - Zip Code:28676-9021
Mailing Address - Country:US
Mailing Address - Phone:336-413-6735
Mailing Address - Fax:314-996-8479
Practice Address - Street 1:180 PARKWOOD DRIVE
Practice Address - Street 2:HUGH CHATHAM MEMORIAL HOSPITAL
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621
Practice Address - Country:US
Practice Address - Phone:336-527-7000
Practice Address - Fax:314-996-8479
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003009222367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO919241109Medicaid
IL$$$$$$$$$Medicaid
MO919241109Medicaid
IL$$$$$$$$$001Medicaid
158060042Medicare PIN