Provider Demographics
NPI:1730357153
Name:KOLEK, KRISTI BETH (PA)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:BETH
Last Name:KOLEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 N PINECLIFF DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3380
Mailing Address - Country:US
Mailing Address - Phone:928-380-2611
Mailing Address - Fax:
Practice Address - Street 1:1100 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3260
Practice Address - Country:US
Practice Address - Phone:928-779-7853
Practice Address - Fax:928-774-0508
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ420103Medicaid
AZ3807OtherSTATE LISCENCE
AZ3807OtherSTATE LISCENCE