Basic Information
| Provider Information | |||||||||
| NPI: | 1952411647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGGI | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 W 57TH ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826016445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078719300 | ||||||||
| FaxNumber: | 8557332371 | ||||||||
| Practice Location | |||||||||
| Address1: | 2091 BOX BUTTE AVE STE 700 | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693014458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3087627244 | ||||||||
| FaxNumber: | 3087611249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 290 | WY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 363A00000X | 2412 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 311835 | 01 | WY | BLUE CROSS | OTHER | 970029372 | 01 | RAILROAD MEDICARE | OTHER |