MEDICARE: KRISTINA MARIA WIXON D.O.

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	207Q00000X	Family Medicine Physician	5101021985	MI

General Provider Information

NPI Number	:	1619358793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA MARIA WIXON D.O.

Provider Business Mailing Address
First Line	:	27450 SCHOENHERR RD STE 400
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48088-6684
Country	:	US
Telephone Number	:	586-582-7550
Fax Number	:	586-582-7515

Provider Business Practice Location Address
First Line	:	6000 24 MILE RD
Second Line	:
City	:	SHELBY TWP
State	:	MI
Zip	:	48316-3201
Country	:	US
Telephone Number	:	586-677-3310
Fax Number	:	586-677-3326

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

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	06/05/2018

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