Provider Demographics
NPI:1457404493
Name:JOHANSEN, KRISTA (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:
Last Name:JOHANSEN
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 1:281 LINCOLN ST
Mailing Address - Street 2:MEDICAL STAFF SVCS
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2138
Mailing Address - Country:US
Mailing Address - Phone:508-334-8015
Mailing Address - Fax:
Practice Address - Street 1:281 LINCOLN ST
Practice Address - Street 2:MEDICAL STAFF SVCS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2138
Practice Address - Country:US
Practice Address - Phone:508-334-8015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA218503207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology