Provider Demographics
NPI:1164408126
Name:RUSH, KRISTEL WYN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEL
Middle Name:WYN
Last Name:RUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 W SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-5327
Mailing Address - Country:US
Mailing Address - Phone:907-376-2411
Mailing Address - Fax:
Practice Address - Street 1:1363 W SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-5327
Practice Address - Country:US
Practice Address - Phone:907-376-2411
Practice Address - Fax:907-352-3301
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38153207Q00000X
AKAK4562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMEDS4562OtherPROFESSIONAL LICENSE
AK1013546Medicaid