Provider Demographics
NPI:1437476538
Name:KRIS H WUSTERHAUSEN DO PA
Entity Type:Organization
Organization Name:KRIS H WUSTERHAUSEN DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:WUSTERHAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-845-8322
Mailing Address - Street 1:747 S SUGARTREE DR
Mailing Address - Street 2:
Mailing Address - City:LIPAN
Mailing Address - State:TX
Mailing Address - Zip Code:76462-4328
Mailing Address - Country:US
Mailing Address - Phone:817-845-8322
Mailing Address - Fax:
Practice Address - Street 1:747 S SUGARTREE DR
Practice Address - Street 2:
Practice Address - City:LIPAN
Practice Address - State:TX
Practice Address - Zip Code:76462-4328
Practice Address - Country:US
Practice Address - Phone:817-845-8322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8703313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH39682Medicare UPIN