Provider Demographics
NPI:1629365408
Name:VIDRINE, KRISTINA N (PA)
Entity Type:Individual
Prefix:MISS
First Name:KRISTINA
Middle Name:N
Last Name:VIDRINE
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 1:920 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3112
Mailing Address - Country:US
Mailing Address - Phone:504-349-6804
Mailing Address - Fax:504-349-6844
Practice Address - Street 1:920 AVENUE B
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3112
Practice Address - Country:US
Practice Address - Phone:504-349-6804
Practice Address - Fax:504-349-6844
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant