Provider Demographics
NPI:1588843544
Name:MCCUTCHEN, KRISTINA M (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:MCCUTCHEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:M
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:13340 CALIFORNIA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-5255
Mailing Address - Country:US
Mailing Address - Phone:402-614-1999
Mailing Address - Fax:402-934-8119
Practice Address - Street 1:13340 CALIFORNIA ST STE 201
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5255
Practice Address - Country:US
Practice Address - Phone:402-614-1999
Practice Address - Fax:402-934-8119
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1525363A00000X
IL085003105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant