Basic Information
| Provider Information | |||||||||
| NPI: | 1255571451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | KRYSTEN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 GLEN COVE AVE | ||||||||
| Address2: | |||||||||
| City: | SEA CLIFF | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115791455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166761742 | ||||||||
| FaxNumber: | 5166769662 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 GLEN COVE AVE | ||||||||
| Address2: | |||||||||
| City: | SEA CLIFF | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115791455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166761742 | ||||||||
| FaxNumber: | 5166769662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2009 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 012589 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MR1785786 | 01 | NY | DEA | OTHER |