Provider Demographics
NPI:1245346063
Name:RIORDAN, KRYSTEN (PA)
Entity type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:
Last Name:RIORDAN
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 1:7791 SW 42ND CT
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3125
Mailing Address - Country:US
Mailing Address - Phone:754-264-4177
Mailing Address - Fax:954-276-6501
Practice Address - Street 1:801 S DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1355
Practice Address - Country:US
Practice Address - Phone:954-267-6501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101682363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP67289Medicare UPIN
FLE8035YMedicare PIN