Provider Demographics
NPI:1629024856
Name:HALSELL, KRISTIN SUE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SUE
Last Name:HALSELL
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:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:130 N SHERMAN ST
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-9409
Practice Address - Country:US
Practice Address - Phone:517-589-5071
Practice Address - Fax:517-589-5452
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004358363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN79450006Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
P72690Medicare UPIN