Provider Demographics
NPI:1154795227
Name:DECKER, KRISTOPHER WYATT (PA-C)
Entity type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:WYATT
Last Name:DECKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 ASHVILLE AVE STE 10
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6130
Practice Address - Country:US
Practice Address - Phone:919-859-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3643-23363A00000X
NC0010-08659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-005532OtherSTATE OF IL
NC0010-08659OtherSTATE OF NC
WI3643-23OtherSTATE OF WI
MD3729362OtherDEA - WI
MD5346312OtherDEA - NC