Provider Demographics
NPI:1114212792
Name:KINSELLA, CHRISTOPHER R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:R
Last Name:KINSELLA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:4033 TALBOT RD S STE 530
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5700
Practice Address - Country:US
Practice Address - Phone:425-690-3433
Practice Address - Fax:425-690-9433
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61105409208600000X
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114212792Medicaid