NPIMap

Individual provider Active NPI

Cristina Elizabet Hermosillo, PA-C

  • Medical Physician Assistant
  • Kokomo, IN
National Provider Identifier
1104607738
Registry record updated Jan 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
10004249A Issued in IN
Practice address
3118 S Lafountain St
Kokomo, IN 46902-3710
Phone
(765) 864-4160
Fax
(765) 400-4467
NPI assigned
Oct 10, 2023
Sex
Female
Sole proprietor
Yes

Organizations & group practices 17

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 1

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Indiana Medical College, School of Medicine of Purdue University, 2023
Medicare assignment
May accept Medicare assignment
Group practices
Healthnet Inc 77 clinicians
Indiana Health Centers Inc 63 clinicians

Practice addresses (Care Compare)

2855 N Keystone Ave
Suite 120
Indianapolis, IN 46218-2790

3118 S Lafountain St
Kokomo, IN 46902-3710
Phone (765) 864-4160

Hospital & facility affiliations

  • Indiana University Health Hospital, Indianapolis, IN, CCN 150056

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Medicare enrollment records 1

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
I20240129001761 IN Practitioner - Physician Assistant 6507219300 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
10004249AINMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Indiana Health Centers, Inc. Family Medicine Past Accepting new patients
Indiana Health Centers, Inc. Family Medicine Past Accepting new patients

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 10004249A IN Primary

Addresses

NPPES NPI Registry

Primary practice location

3118 S Lafountain St
Kokomo, IN 46902-3710

Mailing address

8003 Castleway Dr
Indianapolis, IN 46250-1946
Phone (317) 576-1335

Other identifiers 1

NPPES NPI Registry
IdentifierTypeStateIssuer
300085790MedicaidIN

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jan 25, 2024.

{
    "created_epoch": "1696896000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1706140800000",
    "number": "1104607738",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8003 CASTLEWAY DR",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462501946",
            "telephone_number": "317-576-1335",
            "fax_number": "317-343-6562"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3118 S LAFOUNTAIN ST",
            "city": "KOKOMO",
            "state": "IN",
            "postal_code": "469023710",
            "telephone_number": "765-864-4160",
            "fax_number": "765-400-4467"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HERMOSILLO",
        "first_name": "CRISTINA",
        "middle_name": "ELIZABET",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2023-10-10",
        "last_updated": "2024-01-25",
        "certification_date": "2024-01-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "IN",
            "license": "10004249A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300085790",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kokomo, IN

Sources for this page

Verify at the official NPI Registry.