Provider Demographics
NPI:1992700884
Name:PEKALA, KRISTIN H (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:H
Last Name:PEKALA
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 1:331 OLCOTT DR
Mailing Address - Street 2:STE U3
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-9601
Mailing Address - Country:US
Mailing Address - Phone:802-295-6132
Mailing Address - Fax:802-295-1358
Practice Address - Street 1:331 OLCOTT DR
Practice Address - Street 2:STE U3
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-9601
Practice Address - Country:US
Practice Address - Phone:802-295-6132
Practice Address - Fax:802-295-1358
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1243Medicaid
VTAP1352Medicare ID - Type Unspecified
VTP17367Medicare UPIN