Healthcare Provider Details

I. General information

NPI: 1164032355
Provider Name (Legal Business Name): KRISTOPHER RYAN KOHOUT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 E TYLER ST
ATHENS TX
75751-2145
US

IV. Provider business mailing address

PO BOX 95559
GRAPEVINE TX
76099-9707
US

V. Phone/Fax

Practice location:
  • Phone: 903-292-5015
  • Fax: 903-292-5021
Mailing address:
  • Phone: 405-724-0574
  • Fax: 405-849-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17918
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: