Provider Demographics
NPI:1659332658
Name:CANTRELL, KRISTIN LEE (PA)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LEE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEE
Other - Last Name:MEYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10630 CLEMSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4545
Practice Address - Country:US
Practice Address - Phone:864-482-6000
Practice Address - Fax:864-482-7000
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC357363A00000X
SCPA357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2212PAMedicaid
SCQ31502Medicare PIN
SCR94679Medicare UPIN