Provider Demographics
NPI:1861887192
Name:ANTILLON, KRESTA S
Entity type:Individual
Prefix:MRS
First Name:KRESTA
Middle Name:S
Last Name:ANTILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC 09 5040
Mailing Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-994-5300
Mailing Address - Fax:505-344-1233
Practice Address - Street 1:145 DON PASQUAL RD NW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8841
Practice Address - Country:US
Practice Address - Phone:505-865-4618
Practice Address - Fax:505-224-8727
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2018-0733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine