Provider Demographics
NPI:1033214606
Name:WHELAN, KRISTY M (DO)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:M
Last Name:WHELAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-0645
Mailing Address - Country:US
Mailing Address - Phone:928-680-4233
Mailing Address - Fax:928-680-6522
Practice Address - Street 1:2082 MESQUITE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6710
Practice Address - Country:US
Practice Address - Phone:928-680-4233
Practice Address - Fax:928-680-6522
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ108996OtherMEDICARE GROUP PTAN
AZ701632Medicaid
AZZ108997OtherMEDICARE INDIVIDUAL PTAN
AZAZ0422120OtherBLUE CROSS BLUE SHIELD #
AZZ108996OtherMEDICARE GROUP PTAN