Provider Demographics
NPI:1891249363
Name:BLUE, KIRSTEN
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 PINE HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:FL
Mailing Address - Zip Code:32732-9042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant