Provider Demographics
NPI:1548894454
Name:ETTLIN, KRISTEN AMANDA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:AMANDA
Last Name:ETTLIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:AMANDA
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4140 HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-3848
Mailing Address - Country:US
Mailing Address - Phone:573-544-7907
Mailing Address - Fax:
Practice Address - Street 1:HARRY S. TRUMAN MEMORIAL VETERANS HOSPITAL
Practice Address - Street 2:800 HOSPITAL DRIVE
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-814-6565
Practice Address - Fax:573-814-6176
Is Sole Proprietor?:No
Enumeration Date:2020-02-29
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021001164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant