Provider Demographics
NPI:1437475928
Name:WALLS, KRISTEN S (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:S
Last Name:WALLS
Suffix:
Gender:F
Credentials:PA-C
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF CRITICAL CARE
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-443-0344
Practice Address - Fax:508-856-0559
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110106027AMedicaid