Provider Demographics
NPI:1104263474
Name:SODOLAK, KRISTIN NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:SODOLAK
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 1:17521 ST LUKES WAY
Mailing Address - Street 2:SUITE 190
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8039
Mailing Address - Country:US
Mailing Address - Phone:281-719-5446
Mailing Address - Fax:936-447-5444
Practice Address - Street 1:17521 ST LUKES WAY
Practice Address - Street 2:SUITE 190
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-8039
Practice Address - Country:US
Practice Address - Phone:281-719-5446
Practice Address - Fax:936-447-5444
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08438363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical