Provider Demographics
NPI:1710071634
Name:LUPTON, KRISTIN LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LEIGH
Last Name:LUPTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7705
Mailing Address - Country:US
Mailing Address - Phone:703-371-6644
Mailing Address - Fax:
Practice Address - Street 1:2501 PARKERS LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3209
Practice Address - Country:US
Practice Address - Phone:703-664-7264
Practice Address - Fax:703-664-7190
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104418363AS0400X
VA0110001685363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2930544 00Medicaid
FL2930544 00Medicaid