Healthcare Provider Details

I. General information

NPI: 1780210229
Provider Name (Legal Business Name): KRISTOPHER F WILEY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 22ND ST
LUBBOCK TX
79410-1139
US

IV. Provider business mailing address

7304 KEWANEE AVE
LUBBOCK TX
79424-7075
US

V. Phone/Fax

Practice location:
  • Phone: 806-725-0019
  • Fax:
Mailing address:
  • Phone: 806-535-2447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number823088
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: