Provider Demographics
NPI:1134393416
Name:WELSH, KRISTINE (PA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:WELSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-1913
Mailing Address - Country:US
Mailing Address - Phone:203-579-5000
Mailing Address - Fax:
Practice Address - Street 1:982 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-1913
Practice Address - Country:US
Practice Address - Phone:203-579-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3153363AM0700X
CT75381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical