Provider Demographics
NPI:1497269781
Name:WELBOURN, KRISTIN JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JOY
Last Name:WELBOURN
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 1:9 WOODWARD HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT RIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48069-1246
Mailing Address - Country:US
Mailing Address - Phone:248-240-7032
Mailing Address - Fax:
Practice Address - Street 1:3600 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6711
Practice Address - Country:US
Practice Address - Phone:248-549-0777
Practice Address - Fax:248-549-5888
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical