Provider Demographics
NPI:1922167550
Name:GORMAN, KRISTA R (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:R
Last Name:GORMAN
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 1:55 MAUI LANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2416
Mailing Address - Country:US
Mailing Address - Phone:808-243-6050
Mailing Address - Fax:
Practice Address - Street 1:55 MAUI LANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-243-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101480363A00000X
HIAMD-1025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP26457Medicare UPIN