Provider Demographics
NPI:1306831599
Name:WILLISON, KRISTEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:
Last Name:WILLISON
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 1:50 S SAN MATEO DR
Mailing Address - Street 2:230
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3857
Mailing Address - Country:US
Mailing Address - Phone:650-348-0454
Mailing Address - Fax:650-348-7923
Practice Address - Street 1:50 S SAN MATEO DR
Practice Address - Street 2:230
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3857
Practice Address - Country:US
Practice Address - Phone:650-348-0454
Practice Address - Fax:650-348-7923
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG072317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ14137ZMedicare ID - Type Unspecified
CAF05947Medicare UPIN