Provider Demographics
NPI:1548275092
Name:OVERTON, KRISTIN C (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:C
Last Name:OVERTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 JOLLEY DR STE 301
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-4228
Mailing Address - Country:US
Mailing Address - Phone:860-242-3000
Mailing Address - Fax:860-286-9547
Practice Address - Street 1:35 JOLLEY DR STE 301
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-4228
Practice Address - Country:US
Practice Address - Phone:860-242-3000
Practice Address - Fax:860-286-9547
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000798363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P03512Medicare UPIN
970000814Medicare ID - Type Unspecified