Provider Demographics
NPI:1770350761
Name:PROVENCIO, KRYSTEN
Entity type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S DOBSON RD STE 305
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6490
Mailing Address - Country:US
Mailing Address - Phone:480-756-6000
Mailing Address - Fax:
Practice Address - Street 1:13555 W MCDOWELL RD STE 200
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2624
Practice Address - Country:US
Practice Address - Phone:480-756-6000
Practice Address - Fax:855-636-8770
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
AZ10672363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program