Provider Demographics
NPI:1992165583
Name:MAULDIN, KRISTEN LEIGH (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:LEIGH
Last Name:MAULDIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-7103
Mailing Address - Fax:843-763-3834
Practice Address - Street 1:2295 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7801
Practice Address - Country:US
Practice Address - Phone:843-766-7103
Practice Address - Fax:843-763-3834
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2415363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC2415OtherSTATE LICENSE
SCSC79265449Medicare PIN