Provider Demographics
NPI:1578853602
Name:WILSON, KRISTAL LEE ANN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:LEE ANN
Last Name:WILSON
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 1:10302 BROOKRIDGE VILLAGE BLVD STE 103-104
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4475
Mailing Address - Country:US
Mailing Address - Phone:502-576-5300
Mailing Address - Fax:502-576-5376
Practice Address - Street 1:10302 BROOKRIDGE VILLAGE BLVD STE 103-104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4475
Practice Address - Country:US
Practice Address - Phone:502-276-5300
Practice Address - Fax:502-576-5376
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01084557A208VP0014X, 208VP0014X
KY48792208VP0014X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100212070Medicaid
IN201298810Medicaid