Provider Demographics
NPI:1013449537
Name:HWANG, KRISTY S
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:S
Last Name:HWANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 EXECUTIVE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3069
Mailing Address - Country:US
Mailing Address - Phone:770-750-4228
Mailing Address - Fax:
Practice Address - Street 1:4510 EXECUTIVE DR STE 325
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3069
Practice Address - Country:US
Practice Address - Phone:770-750-4228
Practice Address - Fax:404-251-8680
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1731332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program