Provider Demographics
NPI:1063519221
Name:LANDT, KRISTEN J (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:J
Last Name:LANDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:J
Other - Last Name:REALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19726
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-9726
Mailing Address - Country:US
Mailing Address - Phone:772-465-9770
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-567-4311
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant