Healthcare Provider Details

I. General information

NPI: 1861897365
Provider Name (Legal Business Name): KRISTIN SACHS SOUDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 GODWIN BLVD
SUFFOLK VA
23434-8274
US

IV. Provider business mailing address

3241 WESTERN BRANCH BLVD STE A
CHESAPEAKE VA
23321-5260
US

V. Phone/Fax

Practice location:
  • Phone: 757-935-5310
  • Fax: 757-935-5311
Mailing address:
  • Phone: 757-686-3508
  • Fax: 757-686-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-004714
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: