Basic Information
| Provider Information | |||||||||
| NPI: | 1730535865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANKROM | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 MEDICAL PKWY STE 210 | ||||||||
| Address2: | |||||||||
| City: | LAKEWAY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787381793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126541234 | ||||||||
| FaxNumber: | 5126540321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2016 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | S1927 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | S1927 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | BP10057666 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.