Basic Information
Provider Information | |||||||||
NPI: | 1760587919 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHALCK | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | SUZANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCRAE | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: | SUZANNE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1400 E. CHURCH STREET | ||||||||
Address2: | ATTENTION- MEDICAL STAFF OFFICE | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 93454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057393954 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5920 WEST MALL | ||||||||
Address2: |   | ||||||||
City: | ATASCADERO | ||||||||
State: | CA | ||||||||
PostalCode: | 93422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054660676 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 08/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14416 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.