Provider Demographics
NPI:1457633307
Name:GAFFNEY, KRISTIN BOST (PA-C, MSPAS)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:BOST
Last Name:GAFFNEY
Suffix:
Gender:F
Credentials:PA-C, MSPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3707 LARGENT WAY NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:678-581-5729
Practice Address - Fax:678-581-5719
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04394363A00000X
SC1715363AM0700X
GA7932363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1742PAMedicaid
NC1457633307Medicaid
NCNCF068GMedicare PIN
NCNCF068CMedicare PIN
NCNCF068FMedicare PIN
NCNCF068EMedicare PIN
NCNCF068DMedicare PIN
NC1457633307Medicaid
SCSC19467772Medicare PIN
NCNCF068AMedicare PIN