Provider Demographics
NPI:1891227161
Name:KIM, CHRISTINA DIANE (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DIANE
Last Name:KIM
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:DIANE
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:12S
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-2571
Practice Address - Country:US
Practice Address - Phone:214-645-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant