Provider Demographics
NPI: | 1497767917 |
---|---|
Name: | REDNOUR, KRISTINE M (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | KRISTINE |
Middle Name: | M |
Last Name: | REDNOUR |
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: | 282 APOLLO BEACH BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | APOLLO BEACH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33572-2261 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 813-645-4068 |
Mailing Address - Fax: | 813-645-0312 |
Practice Address - Street 1: | 282 APOLLO BEACH BLVD |
Practice Address - Street 2: | |
Practice Address - City: | APOLLO BEACH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33572-2261 |
Practice Address - Country: | US |
Practice Address - Phone: | 813-645-4068 |
Practice Address - Fax: | 813-645-0312 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-13 |
Last Update Date: | 2019-03-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PA9110106 | 363A00000X, 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | P00924300 | Other | RAILROAD MEDICARE PTAN |
IN | 339250A2 | Medicare PIN | |
Q25230 | Medicare UPIN | ||
IN | P00924300 | Other | RAILROAD MEDICARE PTAN |