Provider Demographics
NPI:1184714198
Name:FIELDS, KRISTIN L (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:FIELDS
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 1:400 S KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2682
Mailing Address - Country:US
Mailing Address - Phone:815-928-0860
Mailing Address - Fax:800-505-2218
Practice Address - Street 1:400 S KENNEDY DR
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-2682
Practice Address - Country:US
Practice Address - Phone:815-928-0860
Practice Address - Fax:800-505-2218
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001387363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201199Medicare PIN