Healthcare Provider Details

I. General information

NPI: 1255317350
Provider Name (Legal Business Name): KRISTI LYNN LAROCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MOWRY AVE SUITE 222
FREMONT CA
94538-1605
US

IV. Provider business mailing address

39141 CIVIC CENTER DR SUITE 220
FREMONT CA
94538-5818
US

V. Phone/Fax

Practice location:
  • Phone: 510-818-1160
  • Fax: 510-818-1195
Mailing address:
  • Phone: 510-248-1018
  • Fax: 510-608-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number17772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: