Provider Demographics
NPI:1881096865
Name:LAI, KRISTEN NOEL (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NOEL
Last Name:LAI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:NOEL
Other - Last Name:OCHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 N WICKHAM RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8662
Mailing Address - Country:US
Mailing Address - Phone:321-253-1992
Mailing Address - Fax:321-253-1844
Practice Address - Street 1:240 N WICKHAM RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8662
Practice Address - Country:US
Practice Address - Phone:321-253-1992
Practice Address - Fax:321-253-1844
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004064363A00000X
FLPA9109983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH401320OtherMEDICARE PTAN
OH0111689Medicaid