Healthcare Provider Details

I. General information

NPI: 1053461632
Provider Name (Legal Business Name): KRISTIN K. WICKSTROM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 10/24/2020
Certification Date: 10/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 WORCESTER RD BARRE FAMILY HEALTH CENTER
BARRE MA
01005-9002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 978-355-6321
  • Fax: 978-355-6329
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2210
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: