Provider Demographics
NPI:1568732600
Name:POOLE, KRISTEN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:POOLE
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:PO BOX 643822
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-3822
Mailing Address - Country:US
Mailing Address - Phone:800-599-0207
Mailing Address - Fax:
Practice Address - Street 1:420 N CENTER ST
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-5033
Practice Address - Country:US
Practice Address - Phone:828-315-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC4442AMedicare PIN