Provider Demographics
NPI:1780603985
Name:FORD, KRISTINA ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ANN
Last Name:FORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KRISTNA
Other - Middle Name:ANN
Other - Last Name:KROTOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2330
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-2330
Mailing Address - Country:US
Mailing Address - Phone:843-689-5002
Mailing Address - Fax:843-689-3690
Practice Address - Street 1:25 HOSPITAL CENTER COMMON
Practice Address - Street 2:SUITE 200
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-689-5002
Practice Address - Fax:843-689-3690
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103616363A00000X
SC1217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ79481Medicare UPIN
FLAC984ZMedicare PIN
SCAC984ZMedicare PIN