Basic Information
| Provider Information | |||||||||
| NPI: | 1326089202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | ARRIETA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARRIETA | ||||||||
| OtherFirstName: | KRISTINE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1760 E RIVER ROAD | ||||||||
| Address2: | 350 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205197720 | ||||||||
| FaxNumber: | 5205195181 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 N CRAYCROFT RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203242409 | ||||||||
| FaxNumber: | 5203242454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2818 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 133599 | 05 | AZ | MEDICAID |