Provider Demographics
NPI:1285057265
Name:TODD, KRISTINA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:TODD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 E BASELINE RD STE 124
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2969
Mailing Address - Country:US
Mailing Address - Phone:480-832-2213
Mailing Address - Fax:
Practice Address - Street 1:4915 E BASELINE RD STE 124
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2969
Practice Address - Country:US
Practice Address - Phone:480-832-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5595363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical