Provider Demographics
NPI:1104248772
Name:MASSIMO, KRISTIN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:MASSIMO
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 1:13111 EAST FWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-5803
Mailing Address - Country:US
Mailing Address - Phone:203-217-2263
Mailing Address - Fax:
Practice Address - Street 1:13111 EAST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-5803
Practice Address - Country:US
Practice Address - Phone:203-217-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08773363A00000X
NJ25MP00437800363A00000X
PAAO004787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00437800Medicaid