Provider Demographics
NPI:1922401108
Name:KAINE, KRISTAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:
Last Name:KAINE
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 1:763 G AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2178
Mailing Address - Country:US
Mailing Address - Phone:619-300-2210
Mailing Address - Fax:
Practice Address - Street 1:11425 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2045
Practice Address - Country:US
Practice Address - Phone:858-794-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15533363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical