Provider Demographics
NPI:1992801864
Name:HALL, KRISTI HAWKINS (PAC)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:HAWKINS
Last Name:HALL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:LYNN
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:360 AMSDEN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1851
Mailing Address - Country:US
Mailing Address - Phone:859-873-9188
Mailing Address - Fax:859-873-0870
Practice Address - Street 1:360 AMSDEN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1851
Practice Address - Country:US
Practice Address - Phone:859-873-9188
Practice Address - Fax:859-873-0870
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001111Medicaid
P25512Medicare UPIN
KY0905225Medicare ID - Type Unspecified
KY0169Medicare PIN
KY95001111Medicaid
KY0693033Medicare ID - Type Unspecified
KYK007401Medicare PIN