Provider Demographics
NPI:1508291410
Name:FOGLE, KRISTY MICHELLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:MICHELLE
Last Name:FOGLE
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 1:31 COOLPOND CT
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-3839
Mailing Address - Country:US
Mailing Address - Phone:443-848-8705
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT ROAD
Practice Address - Street 2:NORTHWEST HOSPITAL-EMERGENCY DEPARTMENT
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133
Practice Address - Country:US
Practice Address - Phone:443-848-8705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005156363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical