Provider Demographics
NPI:1992070486
Name:SCROGGINS, KRISTEN NICOLE (PA)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:SCROGGINS
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-510-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX896N90OtherBCBS
TXP01200611OtherRAIL ROAD
TX315609301Medicaid
TX752616977042OtherTRICARE
TX75-2616977-007OtherTRICARE
TX75-2616977-007OtherTRICARE