Healthcare Provider Details

I. General information

NPI: 1033329750
Provider Name (Legal Business Name): KRISTEN LYNN SMOL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 16TH ST
OAKLAND CA
94612-1205
US

IV. Provider business mailing address

616 16TH ST
OAKLAND CA
94612-1205
US

V. Phone/Fax

Practice location:
  • Phone: 510-563-4300
  • Fax:
Mailing address:
  • Phone: 510-451-4270
  • Fax: 510-451-4285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: