Provider Demographics
NPI:1649906660
Name:BRUCE, KRISTEN KETURAH (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KETURAH
Last Name:BRUCE
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 1:8205 CORNITH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1419
Mailing Address - Country:US
Mailing Address - Phone:804-310-6520
Mailing Address - Fax:
Practice Address - Street 1:1730 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2807
Practice Address - Country:US
Practice Address - Phone:540-773-8169
Practice Address - Fax:540-773-8170
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008718363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant