Provider Demographics
NPI:1558351569
Name:CHRISTENSEN, KRISTIN A (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:CHRISTENSEN
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 1:381 S MIDDLETON RD STE B
Mailing Address - Street 2:SUITE 115
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5369
Mailing Address - Country:US
Mailing Address - Phone:208-585-6311
Mailing Address - Fax:208-585-6221
Practice Address - Street 1:381 S MIDDLETON RD STE B
Practice Address - Street 2:SUITE 115
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-5369
Practice Address - Country:US
Practice Address - Phone:208-585-6311
Practice Address - Fax:208-585-6221
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805233800Medicaid
ID970019572OtherRAILROAD MEDICARE
IDPA811OtherBLUE CROSS
ID000010017487OtherBLUE SHIELD
ID000010017488OtherBLUE SHIELD
IDPA860OtherBLUE CROSS
P32378Medicare UPIN
1666946Medicare PIN