Healthcare Provider Details

I. General information

NPI: 1922401108
Provider Name (Legal Business Name): KRISTAN KAINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11425 EL CAMINO REAL
SAN DIEGO CA
92130-2045
US

IV. Provider business mailing address

763 G AVE
CORONADO CA
92118-2178
US

V. Phone/Fax

Practice location:
  • Phone: 858-794-6363
  • Fax:
Mailing address:
  • Phone: 619-300-2210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: