Provider Demographics
NPI:1265590996
Name:MAIESE, KRISTI (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:MAIESE
Suffix:
Gender:F
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 1:4755 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 1E50
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-0001
Mailing Address - Country:US
Mailing Address - Phone:302-733-1980
Mailing Address - Fax:302-733-1987
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 1E50
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-0001
Practice Address - Country:US
Practice Address - Phone:302-733-1980
Practice Address - Fax:302-733-1987
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000502363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0000502OtherPROFESSIONAL LICENSE
DEC5-0000502OtherPROFESSIONAL LICENSE