Provider Demographics
NPI:1598743593
Name:MULLINS, KRISTINA DAWN (PA C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:DAWN
Last Name:MULLINS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:DAWN
Other - Last Name:CHAFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:14827 SOARING EAGLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1827
Mailing Address - Country:US
Mailing Address - Phone:304-881-6417
Mailing Address - Fax:
Practice Address - Street 1:14827 SOARING EAGLE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1827
Practice Address - Country:US
Practice Address - Phone:304-881-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00830363A00000X
OH50-002366363A00000X
NC0010-00891363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0127974000OtherMEDICAID
WV0127483000Medicaid
WV0126752000OtherMEDICAID
WV0126874000OtherMEDICAID
WV0126874000OtherMEDICAID
WV0127483000Medicaid
WV0127483000Medicaid