Provider Demographics
NPI:1154791572
Name:PALLESEN, KRISTOPHER (PTA)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:PALLESEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-4704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5910 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-4704
Practice Address - Country:US
Practice Address - Phone:209-475-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11071174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist