Provider Demographics
NPI:1366980302
Name:WASON, KRISTIN FARRELL
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:FARRELL
Last Name:WASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:FARRELL
Other - Last Name:WENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:801 MASSACHUSETTS AVE
Mailing Address - Street 2:SECOND FLOOR, SUITE 2027D
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2605
Mailing Address - Country:US
Mailing Address - Phone:617-414-4176
Mailing Address - Fax:617-414-4231
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:GENERAL INTERNAL MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-414-5951
Practice Address - Fax:617-414-9157
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2262692261QR0405X, 363LG0600X, 363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110122621AMedicaid