Provider Demographics
NPI:1316696685
Name:DEAN, KRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DEAN
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 1:992 BRINKLEY CT
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1823
Mailing Address - Country:US
Mailing Address - Phone:970-397-8485
Mailing Address - Fax:
Practice Address - Street 1:992 BRINKLEY CT
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1823
Practice Address - Country:US
Practice Address - Phone:970-397-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9115509OtherDEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE