Healthcare Provider Details

I. General information

NPI: 1861644734
Provider Name (Legal Business Name): KRISTIE L SHIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 MIDTOWN RD
PERU IL
61354-1274
US

IV. Provider business mailing address

600 E 1ST ST
SPRING VALLEY IL
61362-1512
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-0203
  • Fax:
Mailing address:
  • Phone: 815-664-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number385.002340
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: