Provider Demographics
NPI:1336175421
Name:ROORK, KRISTIN MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
Last Name:ROORK
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:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-0486
Mailing Address - Country:US
Mailing Address - Phone:307-367-4640
Mailing Address - Fax:307-367-4640
Practice Address - Street 1:221 EAST MAGNOLIA STREET
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941-2099
Practice Address - Country:US
Practice Address - Phone:307-367-2099
Practice Address - Fax:307-367-8889
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYR04566Medicare UPIN