Provider Demographics
NPI:1851427231
Name:FORNER, KRISTIN D (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:D
Last Name:FORNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7503 SURRATTS RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-877-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01775207L00000X, 207LH0002X
CAA120875207LH0002X
MDD0088905207LH0002X
DCMD047245207LH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCM197AMedicare PIN