Provider Demographics
NPI:1770523557
Name:KISTEMAKER, THEODORE PRINS (PA-C)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:PRINS
Last Name:KISTEMAKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1701 WESTCHESTER DR
Mailing Address - Street 2:STE 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7008
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:3333 BROOKVIEW HILLS BLVD
Practice Address - Street 2:STE 207
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5661
Practice Address - Country:US
Practice Address - Phone:336-765-5250
Practice Address - Fax:336-659-0953
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-04-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC103628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2757939Medicare PIN
P8477Medicare UPIN
P00115135Medicare PIN