Basic Information
Provider Information | |||||||||
NPI: | 1780005488 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOHERTY | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DELL | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 339 CONSORT DR | ||||||||
Address2: |   | ||||||||
City: | BALLWIN | ||||||||
State: | MO | ||||||||
PostalCode: | 630114439 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6363869224 | ||||||||
FaxNumber: | 6363867679 | ||||||||
Practice Location | |||||||||
Address1: | 615 S. NEW BALLAS RD. | ||||||||
Address2: | DEPT. OF ANESTHESIOLOGY | ||||||||
City: | ST. LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 63141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142514687 | ||||||||
FaxNumber: | 6363867679 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/23/2013 | ||||||||
LastUpdateDate: | 10/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2014016080 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
No ID Information.