Provider Demographics
NPI:1477969186
Name:WACKELIN, KRISTEN LEIGH EASEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH EASEY
Last Name:WACKELIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEIGH
Other - Last Name:EASEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1540 S. TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239
Mailing Address - Country:US
Mailing Address - Phone:941-917-0060
Mailing Address - Fax:941-957-4248
Practice Address - Street 1:1540 S. TAMIAMI TRAIL
Practice Address - Street 2:SUITE 401
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-917-0060
Practice Address - Fax:941-957-4248
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012578900Medicaid