Provider Demographics
NPI:1104607738
Name:HERMOSILLO, CRISTINA ELIZABET (PA-C)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:ELIZABET
Last Name:HERMOSILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:317-576-1335
Mailing Address - Fax:317-343-6562
Practice Address - Street 1:3118 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3710
Practice Address - Country:US
Practice Address - Phone:765-864-4160
Practice Address - Fax:765-400-4467
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2024-01-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10004249A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300085790Medicaid