1841282357 NPI number — KRISTINE JOST WINDOM PAC

Table of content: KRISTINE JOST WINDOM PAC (NPI 1841282357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841282357 NPI number — KRISTINE JOST WINDOM PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINDOM
Provider First Name:
KRISTINE
Provider Middle Name:
JOST
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOST
Provider Other First Name:
KRISTINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841282357
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
975 SE SANDY BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97214-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-236-0775
Provider Business Mailing Address Fax Number:
503-236-0786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9155 SW BARNES RD
Provider Second Line Business Practice Location Address:
SUITE 440
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-6625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-297-3766
Provider Business Practice Location Address Fax Number:
503-297-8148
Provider Enumeration Date:
08/19/2005

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: 363AS0400X , with the licence number:  PA00978 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: PA10004840 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 500602008 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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