Provider Demographics
NPI:1144531161
Name:CRABTREE-WILSON, KELLI LYNN (MD)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:CRABTREE-WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:LYNN
Other - Last Name:CRABTREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:325 MAINE STREET
Mailing Address - Street 2:MSO LIBRARY
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-505-2988
Mailing Address - Fax:
Practice Address - Street 1:1130 W 4TH ST STE 3204
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1345
Practice Address - Country:US
Practice Address - Phone:785-505-5815
Practice Address - Fax:785-505-5278
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39102207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201138420AMedicaid
KS30004160880001Medicaid
KS068002397OtherMEDICARE PTAN