Provider Demographics
NPI:1982735726
Name:SMITH, KRISTIN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:SMITH
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 1:11370 ANDERSON ST
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2890
Mailing Address - Fax:909-558-2891
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE 2600
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2062
Practice Address - Fax:909-558-2890
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 18318363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA183182Medicare PIN
CAOPA183185Medicare PIN
CAOPA183180Medicare PIN
CAQ66298Medicare UPIN
CAWPA18318CMedicare PIN
CAOPA183184Medicare PIN
CAOPA183181Medicare PIN
CAWPA18318BMedicare PIN
CAOPA183183Medicare PIN
CAWPA18318AMedicare PIN