Provider Demographics
NPI:1780642397
Name:WELLS, KRISTEN M (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:WELLS
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 1:1626 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1501
Mailing Address - Country:US
Mailing Address - Phone:608-355-6868
Mailing Address - Fax:608-355-7001
Practice Address - Street 1:1626 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1501
Practice Address - Country:US
Practice Address - Phone:608-355-6868
Practice Address - Fax:608-355-7001
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44601-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780642397Medicaid
WIP01543169Medicare PIN
WIK400176918Medicare PIN
H68957Medicare UPIN
WI005357155Medicare PIN
WI1040778OtherPHYSICIANS PLUS
WI34261100Medicaid