Provider Demographics
NPI:1609313139
Name:WALLS, KRISTEN ANN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:WALLS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANN
Other - Last Name:VENHUIZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3409
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78691-3409
Mailing Address - Country:US
Mailing Address - Phone:512-202-3830
Mailing Address - Fax:512-354-1106
Practice Address - Street 1:4001 W 15TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5837
Practice Address - Country:US
Practice Address - Phone:214-473-7671
Practice Address - Fax:214-473-7680
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA11087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX387287101Medicaid