Provider Demographics
NPI:1447796172
Name:HALVORSON, KRISTEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:HALVORSON
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 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:267-339-7843
Mailing Address - Fax:
Practice Address - Street 1:517 ROUTE 72 W STE J
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2821
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00674500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1181082OtherNCCPA CERTIFICATION NUMBER