Provider Demographics
NPI:1679898100
Name:COLONNA, KRISTI LYNN (PA)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:COLONNA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:LYNN
Other - Last Name:MASARYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8010 S 18TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1311 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5707
Practice Address - Country:US
Practice Address - Phone:602-322-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-27
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2672363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical