Basic Information
| Provider Information | |||||||||
| NPI: | 1821405671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYLIN | ||||||||
| FirstName: | KRISTAL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GEARHART | ||||||||
| OtherFirstName: | KRISTAL | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 S LAFOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657763020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10001675A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 10001675A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.