Provider Demographics
NPI:1508110339
Name:HOGE, KRYSTAL LOUISE
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LOUISE
Last Name:HOGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:LOUISE
Other - Last Name:WEIGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PNP
Mailing Address - Street 1:2736 GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1033
Mailing Address - Country:US
Mailing Address - Phone:408-205-2518
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18223363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics