1093763559 NPI number — KRISTY L. PUTTS PA-C

Table of content: KRISTY L. PUTTS PA-C (NPI 1093763559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093763559 NPI number — KRISTY L. PUTTS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUTTS
Provider First Name:
KRISTY
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093763559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 BLYTHE BLVD.
Provider Second Line Business Mailing Address:
SUITE 300 - CARDIAC SURGERY:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28203-5863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-373-0212
Provider Business Mailing Address Fax Number:
704-372-1249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 BLYTHE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 300 - CARDIAC SURGERY:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28203-5863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-373-0212
Provider Business Practice Location Address Fax Number:
704-372-1249
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  0010-00095 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0811PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8101666 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1093763559 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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