Healthcare Provider Details

I. General information

NPI: 1770350761
Provider Name (Legal Business Name): KRYSTEN PROVENCIO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 CALLE DE LA PLATA STE 330
LAGUNA HILLS CA
92653-7624
US

IV. Provider business mailing address

2995 RED HILL AVE STE 200
COSTA MESA CA
92626-5984
US

V. Phone/Fax

Practice location:
  • Phone: 949-829-5533
  • Fax: 949-581-9158
Mailing address:
  • Phone: 949-829-5533
  • Fax: 949-581-9158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number65129
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: