Healthcare Provider Details

I. General information

NPI: 1326271412
Provider Name (Legal Business Name): KRISTIN MYERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

896 WASHINGTON ST
MIDDLETOWN CT
06457-2912
US

IV. Provider business mailing address

PO BOX 400
WALLINGFORD CT
06492-7048
US

V. Phone/Fax

Practice location:
  • Phone: 860-788-3632
  • Fax: 860-788-2085
Mailing address:
  • Phone: 203-284-2800
  • Fax: 203-294-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002320
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: