Basic Information
| Provider Information | |||||||||
| NPI: | 1760741219 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KRISTOFFERSON MEDICAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 GATEWAY BLVD W | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799253331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157791716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3280 JOE BATTLE BLVD | ||||||||
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| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799382622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9154741798 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2012 | ||||||||
| LastUpdateDate: | 05/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | KRISTOFFERSON | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9159154741798 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA02936 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.