Provider Demographics
NPI:1104395193
Name:FODOR, KRISTINA (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:FODOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:MISCHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2709 N TEJON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6231
Mailing Address - Country:US
Mailing Address - Phone:719-473-0872
Mailing Address - Fax:
Practice Address - Street 1:2709 N TEJON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6231
Practice Address - Country:US
Practice Address - Phone:719-473-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2024-09-12
Deactivation Date:2020-08-17
Deactivation Code:
Reactivation Date:2020-08-28
Provider Licenses
StateLicense IDTaxonomies
COPA.0005425363A00000X
NJ25MP00562900207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty