Provider Demographics
NPI:1467098277
Name:GAGARIN, KIRSTIN LINNE
Entity Type:Individual
Prefix:MS
First Name:KIRSTIN
Middle Name:LINNE
Last Name:GAGARIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041-151 SOQUEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 CALDWELL DRIVE
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2055
Practice Address - Country:US
Practice Address - Phone:831-576-3000
Practice Address - Fax:831-607-2662
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4319851225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist