Provider Demographics
NPI:1518235217
Name:HOUSE, KRISTIN JANE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JANE
Last Name:HOUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:4446 WASHINGTON RD
Practice Address - Street 2:STE # 7
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6360
Practice Address - Country:US
Practice Address - Phone:706-774-7263
Practice Address - Fax:706-774-7230
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant