Healthcare Provider Details

I. General information

NPI: 1841535309
Provider Name (Legal Business Name): KRISTEN A BUERSTATTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN A VAHLE PA

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 BROADWAY ST
QUINCY IL
62301-2719
US

IV. Provider business mailing address

1005 BROADWAY ST
QUINCY IL
62301-2834
US

V. Phone/Fax

Practice location:
  • Phone: 217-214-3424
  • Fax: 217-221-1344
Mailing address:
  • Phone: 217-223-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009530
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023040348
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: