Basic Information
| Provider Information | |||||||||
| NPI: | 1417939661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | KEDIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026496507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084777090 | ||||||||
| FaxNumber: | 5084777028 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026496507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084777090 | ||||||||
| FaxNumber: | 5084777028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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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 | 207Q00000X | 223219 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 5101017130 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2107465 | 05 | MA | MEDICAID |