Provider Demographics
NPI:1669486155
Name:WYRICK, KRISTEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:WYRICK
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:360-454-1900
Mailing Address - Fax:360-454-1991
Practice Address - Street 1:2901 174TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-4743
Practice Address - Country:US
Practice Address - Phone:360-454-1900
Practice Address - Fax:360-454-1991
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA0101237234207Q00000X
SC39957207Q00000X
WAMD60834504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC399571Medicaid
SC399571Medicaid