Provider Demographics
NPI:1578643250
Name:DAVIS, KRISTEN B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:B
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:RENEE
Other - Last Name:BLACKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:21446 ENTRADA RD
Mailing Address - Street 2:
Mailing Address - City:TOPANGA
Mailing Address - State:CA
Mailing Address - Zip Code:90290-3539
Mailing Address - Country:US
Mailing Address - Phone:323-377-4679
Mailing Address - Fax:
Practice Address - Street 1:21446 ENTRADA RD
Practice Address - Street 2:
Practice Address - City:TOPANGA
Practice Address - State:CA
Practice Address - Zip Code:90290-3539
Practice Address - Country:US
Practice Address - Phone:323-377-4679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22285363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578643250OtherNPI
PA27762Medicare PIN