Provider Demographics
NPI:1255501896
Name:FARRIS, KRISTEN M (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:M
Last Name:FARRIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:NORTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:20 PROGRESS POINT PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-2207
Mailing Address - Country:US
Mailing Address - Phone:636-344-3105
Mailing Address - Fax:
Practice Address - Street 1:20 PROGRESS POINT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2207
Practice Address - Country:US
Practice Address - Phone:636-344-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008018164207P00000X, 363A00000X
IL085003199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO132090002Medicare PIN
MO147400033Medicare PIN