Provider Demographics
NPI:1982011698
Name:WARD, KRISTEN ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:WARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:KANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:125 S CLARK ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-4043
Mailing Address - Country:US
Mailing Address - Phone:151-276-7614
Mailing Address - Fax:
Practice Address - Street 1:982 TIOGUE AVE
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-6116
Practice Address - Country:US
Practice Address - Phone:401-821-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3642363A00000X
MAPA6126363A00000X
WI3642-23363A00000X
RIPA00766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400251943Medicare PIN
WIK400251941Medicare PIN