Basic Information
| Provider Information | |||||||||
| NPI: | 1598119869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRESHA | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23900 KATY FWY | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774941323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816447000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23900 KATY FWY | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774941323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816447000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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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 | 207P00000X | S2622 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 05 | TX | MEDICAID |