Provider Demographics
NPI:1790942910
Name:WATKINS, CRISTYN (MD)
Entity Type:Individual
Prefix:DR
First Name:CRISTYN
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRISTYN
Other - Middle Name:
Other - Last Name:GLIDEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5001 LAKE AVE
Mailing Address - Street 2:SAINT JOSEPH
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64504-1170
Mailing Address - Country:US
Mailing Address - Phone:816-238-7788
Mailing Address - Fax:816-238-9285
Practice Address - Street 1:5001 LAKE AVE
Practice Address - Street 2:SAINT JOSEPH
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64504-1170
Practice Address - Country:US
Practice Address - Phone:816-238-7788
Practice Address - Fax:816-238-9285
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009016625207Q00000X
KS04-33784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200614390AMedicaid
MO1790942910Medicaid
F29A00015Medicare Oscar/Certification
MO1790942910Medicaid