Provider Demographics
NPI:1154341584
Name:KRISTOFFERSON, KEN KIM (PA)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:KIM
Last Name:KRISTOFFERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 REMCON CIR
Mailing Address - Street 2:BLDG A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3529
Mailing Address - Country:US
Mailing Address - Phone:915-532-8823
Mailing Address - Fax:915-532-5909
Practice Address - Street 1:7420 REMCON CIRCLE
Practice Address - Street 2:BLDG. A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912
Practice Address - Country:US
Practice Address - Phone:915-532-8823
Practice Address - Fax:915-532-5909
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02936363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02936OtherPA LICENSE
TX192820202Medicaid
NM76300323Medicaid
TX192820203Medicaid
TX8F23359Medicare PIN
TXPA02936OtherPA LICENSE
TX8L21791Medicare PIN