Provider Demographics
NPI:1871015909
Name:JOHN, CHRISTIN
Entity Type:Individual
Prefix:
First Name:CHRISTIN
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3648 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3024
Practice Address - Country:US
Practice Address - Phone:585-736-3503
Practice Address - Fax:585-736-3504
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54623363A00000X
ORPA187403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant