Provider Demographics
NPI:1992775175
Name:SMALL, KRISTI WHITLEY (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:WHITLEY
Last Name:SMALL
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 1:1908 HILCO ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-6307
Mailing Address - Country:US
Mailing Address - Phone:704-983-3855
Mailing Address - Fax:704-985-1031
Practice Address - Street 1:1908 HILCO ST
Practice Address - Street 2:SUITE B
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-6307
Practice Address - Country:US
Practice Address - Phone:704-983-3855
Practice Address - Fax:704-985-1031
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8984978Medicaid
NC0105EOtherBLUE CROSS BLUE SHIELD
NC0105EOtherBLUE CROSS BLUE SHIELD
NC2799885AMedicare ID - Type Unspecified