Provider Demographics
NPI:1770509408
Name:DEAN, KRISTINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:DEAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:M
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-0107
Mailing Address - Country:US
Mailing Address - Phone:231-922-9270
Mailing Address - Fax:231-922-9271
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2349
Practice Address - Country:US
Practice Address - Phone:231-922-9270
Practice Address - Fax:231-922-9271
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002592363A00000X
GA6313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG27604071Medicare PIN
R74828Medicare UPIN