Provider Demographics
NPI:1265043251
Name:WIATREK, KIRSTEN LEIGH
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LEIGH
Last Name:WIATREK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4601
Mailing Address - Country:US
Mailing Address - Phone:210-225-4809
Mailing Address - Fax:
Practice Address - Street 1:410 W CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4601
Practice Address - Country:US
Practice Address - Phone:210-225-4809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist