Provider Demographics
NPI:1427396886
Name:ODEN, KRISTIN NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:ODEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:
Practice Address - Street 1:106 CORPORATE PARK DR # 200300
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7133
Practice Address - Country:US
Practice Address - Phone:704-235-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant