Provider Demographics
NPI:1891162020
Name:KUTAC, KRISTIN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:KUTAC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 S TEXAS AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:936-266-3513
Mailing Address - Fax:713-852-2332
Practice Address - Street 1:3201 UNIVERSITY DR E STE 425
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3479
Practice Address - Country:US
Practice Address - Phone:979-690-4828
Practice Address - Fax:979-690-4829
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical