Provider Demographics
NPI:1992150395
Name:WILSON, KRISTAN M (DC)
Entity type:Individual
Prefix:
First Name:KRISTAN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 N GORE AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2300
Mailing Address - Country:US
Mailing Address - Phone:314-961-7605
Mailing Address - Fax:314-961-7605
Practice Address - Street 1:23 N GORE AVE
Practice Address - Street 2:STE 210
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2300
Practice Address - Country:US
Practice Address - Phone:314-961-7605
Practice Address - Fax:314-961-7605
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor