Provider Demographics
NPI:1215056114
Name:CALDWELL, CHRISTINE MARIE (PA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E AVENIDA DE LOS ARBOLES
Mailing Address - Street 2:SUITE 204
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3003
Mailing Address - Country:US
Mailing Address - Phone:805-492-1015
Mailing Address - Fax:
Practice Address - Street 1:430 E AVENIDA DE LOS ARBOLES
Practice Address - Street 2:SUITE 204
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3003
Practice Address - Country:US
Practice Address - Phone:805-492-1015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22218363A00000X
IA001086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI12098Medicare ID - Type UnspecifiedPROVIDER NUMBER