Basic Information
| Provider Information | |||||||||
| NPI: | 1942295100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HODGES | ||||||||
| FirstName: | CHRISTA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5130 SUNFOREST DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336346327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5130 SUNFOREST DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336346327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/13/2006 | ||||||||
| NPIReactivationDate: | 05/30/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106209 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 01123 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 018814100 | 05 | FL | MEDICAID | 01123 | 01 | WV | STATE LICENSE | OTHER |