Provider Demographics
NPI:1477552495
Name:WIGHT, KRISTEN BARRETT (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:BARRETT
Last Name:WIGHT
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 1:601 JOHN STREET, BOX 42
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:269-969-6123
Mailing Address - Fax:269-969-6122
Practice Address - Street 1:8088 VINEYARD PKWY
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3892
Practice Address - Country:US
Practice Address - Phone:269-286-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004402363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01450005Medicare PIN
MIP0794000Medicare ID - Type Unspecified