Provider Demographics
NPI:1467544106
Name:GREGORY, KIERSTEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:L
Last Name:GREGORY
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 1:1155 MILL ST # M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:975 RYLAND ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1669
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-5225
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1126363A00000X, 363AS0400X
CAPA15122363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04918ZOtherBLUE SHIELD
CA03-0431018OtherTRI CARE
CAGR0093170Medicaid
CA03-0431018OtherTRI CARE
CAGR0093170Medicaid
NVAP158ZMedicare PIN