Provider Demographics
NPI:1245971118
Name:DENHOLM, KRIS B (PA-C)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:B
Last Name:DENHOLM
Suffix:
Gender:M
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 1:21302 LADEENE AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5438
Mailing Address - Country:US
Mailing Address - Phone:310-850-9635
Mailing Address - Fax:
Practice Address - Street 1:12462 PUTNAM ST STE 208
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1049
Practice Address - Country:US
Practice Address - Phone:562-789-5489
Practice Address - Fax:562-789-4416
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X, 363AM0700X
CA61292363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical