Provider Demographics
NPI:1538738232
Name:CHRISTOPHERSON, KEVIN H (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:H
Last Name:CHRISTOPHERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-6636
Mailing Address - Country:US
Mailing Address - Phone:717-270-9446
Mailing Address - Fax:717-270-5669
Practice Address - Street 1:777 BANNOCK ST # MC3240
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-436-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062573207Q00000X, 363AM0700X
COPA0007945207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1039356650001Medicaid