Provider Demographics
NPI:1063702116
Name:MATSCHULLAT, KRISTY ELAINE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:ELAINE
Last Name:MATSCHULLAT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL SREET SUITE 900
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1803
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:1780 E BULLARD AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5861
Practice Address - Country:US
Practice Address - Phone:800-492-4227
Practice Address - Fax:559-646-3652
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006468363A00000X
NVPA0604363A00000X
IL085003971363A00000X
CAPA64279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant