Provider Demographics
NPI:1821162868
Name:WIELAND, KRISTINA M (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:M
Last Name:WIELAND
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 1:4774 LOMA DEL SUR DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-3597
Mailing Address - Country:US
Mailing Address - Phone:915-751-7773
Mailing Address - Fax:915-757-8764
Practice Address - Street 1:4774 LOMA DEL SUR DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3597
Practice Address - Country:US
Practice Address - Phone:915-751-7773
Practice Address - Fax:915-757-8764
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00385544OtherRAILROAD MEDICARE
TX185535502Medicaid
TX125712305Medicaid
TX316425YLPSOtherWELLMED PTAN
TX185535502Medicaid
TXP00385544OtherRAILROAD MEDICARE
TX125712305Medicaid