Provider Demographics
NPI:1174948889
Name:BISHOP, KRYSTEN M (PA)
Entity type:Individual
Prefix:
First Name:KRYSTEN
Middle Name:M
Last Name:BISHOP
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 1:2920 W GRACE ST
Mailing Address - Street 2:APT A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221
Mailing Address - Country:US
Mailing Address - Phone:231-250-5464
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:804-765-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004517363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical