Healthcare Provider Details

I. General information

NPI: 1265654180
Provider Name (Legal Business Name): KRISTI KRISTINE ICE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 EAST EDNA SUITE 102
PHOENIX AZ
85032
US

IV. Provider business mailing address

4605 SOUTH PRIEST DRIVE LOT 291
TEMPE AZ
85282
US

V. Phone/Fax

Practice location:
  • Phone: 602-569-5437
  • Fax: 602-482-4640
Mailing address:
  • Phone: 480-695-0469
  • Fax: 602-482-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3098
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: