Provider Demographics
NPI:1942826458
Name:DAUERNHEIM, KRISTINA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:DAUERNHEIM
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 1:19 DAVIS AVE
Mailing Address - Street 2:4TH FLOOR HOPE TOWER
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 DAVIS AVE
Practice Address - Street 2:4TH FLOOR HOPE TOWER
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-974-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00582200208600000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery