Provider Demographics
NPI:1598745622
Name:KOUSENS, KRISTA MICHELLE (MSPA-C)
Entity type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:MICHELLE
Last Name:KOUSENS
Suffix:
Gender:F
Credentials:MSPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 N TUSTIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3606
Mailing Address - Country:US
Mailing Address - Phone:714-973-8787
Mailing Address - Fax:714-973-8765
Practice Address - Street 1:720 N TUSTIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3606
Practice Address - Country:US
Practice Address - Phone:714-973-8787
Practice Address - Fax:714-973-8765
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant