Provider Demographics
NPI:1245260710
Name:CONONICO, KRISTINE A (PA)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:CONONICO
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 1:1221 SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3258
Mailing Address - Country:US
Mailing Address - Phone:989-772-6700
Mailing Address - Fax:
Practice Address - Street 1:1221 SOUTH DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3258
Practice Address - Country:US
Practice Address - Phone:989-772-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004397363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN82780004Medicare Oscar/Certification
S90088Medicare UPIN