Provider Demographics
NPI:1548594336
Name:BEAVER, KRISTINA COLEMAN (PT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:COLEMAN
Last Name:BEAVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:LYNN
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:900 ROUND VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7552
Mailing Address - Country:US
Mailing Address - Phone:435-658-7350
Mailing Address - Fax:435-435-7360
Practice Address - Street 1:900 ROUND VALLEY DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7552
Practice Address - Country:US
Practice Address - Phone:435-658-7350
Practice Address - Fax:435-658-7360
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6290760-2401225100000X
CA22057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist