Provider Demographics
NPI:1306115290
Name:FOX, KRISTIN BROOKE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:BROOKE
Last Name:FOX
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 1:2141 ACADEMY CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1686
Mailing Address - Country:US
Mailing Address - Phone:720-319-5294
Mailing Address - Fax:
Practice Address - Street 1:2141 ACADEMY CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1686
Practice Address - Country:US
Practice Address - Phone:720-319-5294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003430363A00000X
MEPA1341363A00000X
COPA.0004651363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400205799Medicare PIN