Provider Demographics
NPI:1902882988
Name:PROCHASKA, KRISTIN MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:MARIE
Last Name:PROCHASKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-235-1827
Mailing Address - Fax:704-235-1823
Practice Address - Street 1:128 MEDICAL PARK RD STE 201
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8579
Practice Address - Country:US
Practice Address - Phone:704-235-1827
Practice Address - Fax:704-235-1823
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC0888AMedicare PIN
NCP92041Medicare UPIN