Provider Demographics
NPI:1558463265
Name:TULLY, KRISTY L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:L
Last Name:TULLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:L
Other - Last Name:LASKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:144 EMERYVILLE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-5015
Mailing Address - Country:US
Mailing Address - Phone:724-776-2111
Mailing Address - Fax:724-776-2199
Practice Address - Street 1:144 EMERYVILLE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-5015
Practice Address - Country:US
Practice Address - Phone:724-776-2111
Practice Address - Fax:724-776-2199
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ10551Medicare UPIN