1972642650 NPI number — KRISTIN ADELE HESTDALEN MD

Table of content: KRISTIN ADELE HESTDALEN MD (NPI 1972642650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972642650 NPI number — KRISTIN ADELE HESTDALEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HESTDALEN
Provider First Name:
KRISTIN
Provider Middle Name:
ADELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972642650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4126 TECHNOLOGY WAY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89706-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-687-7573
Provider Business Mailing Address Fax Number:
775-687-7544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 KIRMAN AVE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-1340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
286-277-5982
Provider Business Practice Location Address Fax Number:
775-982-5496
Provider Enumeration Date:
02/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  10215 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)