Basic Information
| Provider Information | |||||||||
| NPI: | 1164408126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSH | ||||||||
| FirstName: | KRISTEL | ||||||||
| MiddleName: | WYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 705 2ND STREET | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074243622 | ||||||||
| FaxNumber: | 9074243275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 38153 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | AK4562 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1013546 | 05 | AK | MEDICAID |