Provider Demographics
NPI:1871802389
Name:RUPERT, KRISTIN NICOLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:RUPERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:3320 BIG SKY DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1036
Mailing Address - Country:US
Mailing Address - Phone:805-708-2836
Mailing Address - Fax:
Practice Address - Street 1:32144 AGOURA RD STE 112
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4043
Practice Address - Country:US
Practice Address - Phone:818-889-2739
Practice Address - Fax:818-889-2747
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA51583363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant