Provider Demographics
NPI:1366795569
Name:MAHER, KRISTINA VANESSA (PA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:VANESSA
Last Name:MAHER
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 1:602 S AUDUBON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4217
Mailing Address - Country:US
Mailing Address - Phone:813-348-4885
Mailing Address - Fax:813-875-4149
Practice Address - Street 1:602 S AUDUBON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4217
Practice Address - Country:US
Practice Address - Phone:813-348-4885
Practice Address - Fax:813-875-4149
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9106824363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical