Provider Demographics
NPI:1932634854
Name:KRISE, KRISTIN ANNE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNE
Last Name:KRISE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:ANNE
Other - Last Name:WISHNOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:15505 ROXBORO DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-8348
Mailing Address - Country:US
Mailing Address - Phone:440-862-7800
Mailing Address - Fax:
Practice Address - Street 1:525 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1619
Practice Address - Country:US
Practice Address - Phone:330-493-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005049RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant