Provider Demographics
NPI:1942294269
Name:CHATHAM, KRISTY LYNN (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:CHATHAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:9401 SW HIGHWAY 200 STE 1001
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-9613
Practice Address - Country:US
Practice Address - Phone:813-321-1786
Practice Address - Fax:813-321-1787
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00251111OtherSRRGA
FL292415300Medicaid
FLU3872Medicare ID - Type UnspecifiedLECANTO LOCATION
FLQ30257Medicare UPIN