Healthcare Provider Details

I. General information

NPI: 1063702116
Provider Name (Legal Business Name): KRISTY ELAINE MATSCHULLAT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 E BULLARD AVE
FRESNO CA
93710-5861
US

IV. Provider business mailing address

2100 POWELL SREET SUITE 900
EMERYVILLE CA
94608-1803
US

V. Phone/Fax

Practice location:
  • Phone: 800-492-4227
  • Fax: 559-646-3652
Mailing address:
  • Phone: 510-350-2600
  • Fax: 510-879-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0006468
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0604
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003971
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: