Provider Demographics
NPI:1457301152
Name:WEGERSON, KRISTAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTAN
Middle Name:A
Last Name:WEGERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53585 NOKOMIS RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-4272
Mailing Address - Country:US
Mailing Address - Phone:715-683-7133
Mailing Address - Fax:715-685-7857
Practice Address - Street 1:53585 NOKOMIS ROAD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:715-685-7857
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN261713700Medicaid
MN261713700Medicaid
MNF92251Medicare UPIN