Provider Demographics
NPI:1306260682
Name:WITZENBURG, KRISTIN R (PAC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:WITZENBURG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:R
Other - Last Name:CHUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1320 RANDALL PL
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-2716
Mailing Address - Country:US
Mailing Address - Phone:515-250-3339
Mailing Address - Fax:
Practice Address - Street 1:1410 SW TRADITION DR STE 110
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9188
Practice Address - Country:US
Practice Address - Phone:515-875-9696
Practice Address - Fax:515-875-9697
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073924363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical