Provider Demographics
NPI:1780933184
Name:GAUDINO, KRISTINA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:GAUDINO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:SCHRADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-8210
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001248083163W00000X
MARN2322901367500000X
VA0024171284367500000X
WV84870367500000X
PARN564090367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD421640701Medicaid
WV9333201OtherGROUP MEDICARE NO.
WVP01140514OtherRRMEDICARE
VA1780933184Medicaid
WV1780933185OtherUNICARE
WV3810024844Medicaid
DC048315100Medicaid
WV2762822OtherHIGHMARK OF WV
WV9167942OtherAETNA
WV0074998OtherOHJFS
WV1780933185OtherCOVENTRY/CARELINK
DC048315100Medicaid
WV3810024844Medicaid
WV1780933185OtherCOVENTRY/CARELINK
DC249713NHDMedicare PIN