Provider Demographics
NPI:1538678289
Name:FOX, KRISTEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:FOX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:S
Other - Last Name:LOHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3309 S 750 W
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3309 S 750 W
Practice Address - Street 2:
Practice Address - City:RUSSIAVILLE
Practice Address - State:IN
Practice Address - Zip Code:46979-9146
Practice Address - Country:US
Practice Address - Phone:765-765-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002315A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009006Medicaid