Provider Demographics
NPI:1902391212
Name:BORMANN, KRISTINA A (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:A
Last Name:BORMANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 NARRAGANSETT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-2915
Mailing Address - Country:US
Mailing Address - Phone:626-674-7030
Mailing Address - Fax:
Practice Address - Street 1:786 THIRD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5826
Practice Address - Country:US
Practice Address - Phone:619-425-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant