Basic Information
| Provider Information | |||||||||
| NPI: | 1043456130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOPERSTEIN | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973460 | ||||||||
| FaxNumber: | 3606041761 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973460 | ||||||||
| FaxNumber: | 3606041761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2008 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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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 | 363AM0700X | PA60071863 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8535171 | 05 | WA | MEDICAID |