Basic Information
| Provider Information | |||||||||
| NPI: | 1780934273 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KRISTINE LICENSED SURGICAL ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 KINGS RD | ||||||||
| Address2: | |||||||||
| City: | DOUBLE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750773028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 9724637247 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 KINGS RD | ||||||||
| Address2: | |||||||||
| City: | DOUBLE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750773028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 9724637247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2012 | ||||||||
| LastUpdateDate: | 09/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | KRUEGER | ||||||||
| AuthorizedOfficialFirstName: | KRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2142272457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | SA00357 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.