Provider Demographics
NPI:1679873657
Name:GARRISON, KRISTEN DYAN (PA)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:DYAN
Last Name:GARRISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:DYAN
Other - Last Name:BARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:12115 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-5509
Mailing Address - Country:US
Mailing Address - Phone:806-531-3977
Mailing Address - Fax:806-531-3978
Practice Address - Street 1:12115 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-5509
Practice Address - Country:US
Practice Address - Phone:806-531-3977
Practice Address - Fax:806-531-3978
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX401910ZNEAMedicare UPIN