Provider Demographics
NPI:1508203597
Name:CARRICO, KIERSTEN RENE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:RENE
Last Name:CARRICO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIERSTEN
Other - Middle Name:RENE
Other - Last Name:YAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10351 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1904
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:260-739-9602
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:SUTIE 2121
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7937
Practice Address - Fax:260-435-7933
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN692190011Medicare PIN