Provider Demographics
NPI:1760852586
Name:HEAGEN, KRISTYN L (PA)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:L
Last Name:HEAGEN
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 1:2105 BRAXTON LN STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-2862
Mailing Address - Country:US
Mailing Address - Phone:336-333-6306
Mailing Address - Fax:336-333-6309
Practice Address - Street 1:2105 BRAXTON LN STE 101
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-2862
Practice Address - Country:US
Practice Address - Phone:336-333-6306
Practice Address - Fax:335-333-6309
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004415363A00000X
NC0010-13679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant