Provider Demographics
NPI:1699747295
Name:PETERSON, KRISTIN (PA-C)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:PETERSON
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 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5101
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7837
Practice Address - Street 1:3205 N ACADEMY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5101
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55431763Medicaid
CO494878Medicare PIN
CO55431763Medicaid
COC494878Medicare Oscar/Certification