Provider Demographics
NPI:1154486546
Name:PARKER, KRISTINA NICOLE (MSPT)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:NICOLE
Last Name:PARKER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:NICOLE
Other - Last Name:KRUGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT
Mailing Address - Street 1:3745 THEODOLITE DR
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9346
Mailing Address - Country:US
Mailing Address - Phone:315-657-6462
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:315-326-0052
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109432251P0200X
NY028956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY204487134OtherBCBS CNY
NY5464900002OtherMEDICARE DME REGION A
NY705517OtherMANAGED PHYSICAL NETWORK
NY000932122002OtherHEALTH NOW
NY204487134OtherBCBS CNY