Basic Information
| Provider Information | |||||||||
| NPI: | 1114165479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARTH | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | PATRICIA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032939590 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 MARIGOLD LN S | ||||||||
| Address2: | |||||||||
| City: | WEST SALEM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546699386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084980375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2009 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209.007424 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 0001237783 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1114165479 | 05 | VA | MEDICAID |