Provider Demographics
NPI:1770679052
Name:OSAN, KRISTIN (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:OSAN
Suffix:
Gender:F
Credentials:PA
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8865 W 400 N STE 120
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9011
Practice Address - Country:US
Practice Address - Phone:219-878-5031
Practice Address - Fax:219-879-5498
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC047363A00000X
IN10001513A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007766Medicaid
KY7100002730Medicaid
KY7100002730Medicaid