MEDICARE: KRISTIE R WILBURN WREN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	39597	TN
2	207V00000X	Obstetrics & Gynecology Physician	P4528	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4105263	OTHER	TN	BLUE CROSS BLUE SHIELD OF TENNESSEE PIN

General Provider Information

NPI Number	:	1295738615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIE R WILBURN WREN MD

Provider Business Mailing Address
First Line	:	PO BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-9032
Country	:	US
Telephone Number	:	214-648-3280
Fax Number	:	214-648-7611

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-9032
Country	:	US
Telephone Number	:	214-648-3280
Fax Number	:	214-648-7611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	04/22/2016

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