Provider Demographics
NPI:1558797209
Name:CHIN, KRISTA L (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:L
Last Name:CHIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:L
Other - Last Name:KIMBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-2976
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-2976
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3221363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558797209Medicaid
WIKIMBAKRIOtherMERCYCARE INSURANCE
WIK400104671-000054176Medicare PIN
WI1558797209Medicaid