Provider Demographics
NPI:1831324896
Name:VASQUEZ, KRISTEN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:NICOLE
Other - Last Name:ROSALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:519 STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5969
Mailing Address - Country:US
Mailing Address - Phone:912-354-9447
Mailing Address - Fax:912-401-0741
Practice Address - Street 1:519 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5969
Practice Address - Country:US
Practice Address - Phone:912-354-9447
Practice Address - Fax:912-401-0741
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0859PAMedicaid
GA350511798CMedicaid
GAP00778518OtherRR MEDICARE
FLPA9110541OtherLICENSE
GA350511798DMedicaid
SC0859PAMedicaid