Healthcare Provider Details

I. General information

NPI: 1922634039
Provider Name (Legal Business Name): KRISTIAN ASHTIN DE NAGEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NW MURRAY RD STE 201
LEES SUMMIT MO
64081-1227
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-2626
  • Fax:
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number61156
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberE-16196
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: