Provider Demographics
NPI:1588206049
Name:GONCALVES, KRISTINA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICOLE
Last Name:GONCALVES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-2408
Mailing Address - Country:US
Mailing Address - Phone:781-281-7081
Mailing Address - Fax:
Practice Address - Street 1:776 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01905-2408
Practice Address - Country:US
Practice Address - Phone:781-282-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7274363A00000X
MEPAN1997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMS5629324OtherDEA