Basic Information
| Provider Information | |||||||||
| NPI: | 1003132036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WESIGHAN | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 HARBOUR PLACE DR | ||||||||
| Address2: | UNIT 3218 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336026758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072574909 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674243 | ||||||||
| FaxNumber: | 7277678612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2010 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 2013-01349 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME119791 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | NC1861 | 05 | SC | MEDICAID | 1003132036 | 05 | NC | MEDICAID |