Provider Demographics
NPI:1063407930
Name:OVADAL, KRISTIN J (PAC)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:J
Last Name:OVADAL
Suffix:
Gender:F
Credentials:PAC
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-541-7500
Mailing Address - Fax:239-541-7501
Practice Address - Street 1:2441 SURFSIDE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-3861
Practice Address - Country:US
Practice Address - Phone:239-541-7500
Practice Address - Fax:239-541-7501
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI608023363AM0700X
FLPA9113677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108406800Medicaid
WI608Medicare UPIN
WI42931600Medicare ID - Type Unspecified