Basic Information
| Provider Information | |||||||||
| NPI: | 1619358793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIXON | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27450 SCHOENHERR RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480886684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827550 | ||||||||
| FaxNumber: | 5865827515 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 24 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SHELBY TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483163201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866773310 | ||||||||
| FaxNumber: | 5866773326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101021985 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.