Provider Demographics
NPI:1689607012
Name:MARSACK, KRISTINA PETERSON (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:PETERSON
Last Name:MARSACK
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 1:2 GREENWAY PLZ
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0297
Mailing Address - Country:US
Mailing Address - Phone:713-798-1750
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:1977 BUTLER BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4101
Practice Address - Country:US
Practice Address - Phone:713-798-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04360363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9178OtherBCBS
TX187010701Medicaid
8J4828Medicare PIN
TX8N9178OtherBCBS
TX187010701Medicaid
TXTXB101507Medicare PIN
8G1710Medicare PIN