MEDICARE: KRISTIN LEGVOLD PAULSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA20466	CA
2	363AS0400X	Surgical Physician Assistant	PA20466	CA
3	363A00000X	Physician Assistant	9145	AZ

General Provider Information

NPI Number	:	1144547738
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN LEGVOLD PAULSON PA-C

Provider Business Mailing Address
First Line	:	230 PROSPECT PL
Second Line	:	SUITE 350
City	:	SAN DIEGO
State	:	CA
Zip	:	92118-1978
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 PROSPECT PL
Second Line	:	SUITE 350
City	:	SAN DIEGO
State	:	CA
Zip	:	92118-1978
Country	:	US
Telephone Number	:	619-437-1388
Fax Number	:	619-437-1857

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2010
Last Update Date	:	09/27/2022

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