MEDICARE: CRISTINA BOSTON SUMMERS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	4551	TN
2	363A00000X	Physician Assistant	0010-09532	NC

General Provider Information

NPI Number	:	1578104238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTINA BOSTON SUMMERS PA-C

Provider Business Mailing Address
First Line	:	509 MED TECH PKWY STE 100
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2579
Country	:	US
Telephone Number	:	423-302-6565
Fax Number	:

Provider Business Practice Location Address
First Line	:	804 ENGLISH RD STE 100
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-6023
Country	:	US
Telephone Number	:	252-467-2069
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2019
Last Update Date	:	05/20/2021

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