Provider Demographics
NPI:1205166295
Name:TANNERY, KRISTA M (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:TANNERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:MARIE
Other - Last Name:LINDSTEDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:550 17TH AVE
Practice Address - Street 2:A FL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5788
Practice Address - Country:US
Practice Address - Phone:206-386-4744
Practice Address - Fax:206-215-1135
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60112541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1205166295OtherNPI
1205166295OtherNPI