Basic Information
Provider Information | |||||||||
NPI: | 1194918409 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOLMES | ||||||||
FirstName: | KIRSTEN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3158 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972083158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032156494 | ||||||||
FaxNumber: | 5032156644 | ||||||||
Practice Location | |||||||||
Address1: | 101 NW 12TH AVE | ||||||||
Address2: | STE 107 | ||||||||
City: | BATTLE GROUND | ||||||||
State: | WA | ||||||||
PostalCode: | 986049141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606876650 | ||||||||
FaxNumber: | 3605146820 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2007 | ||||||||
LastUpdateDate: | 10/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00532 | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA10003545 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1194918409 | 05 | WA |   | MEDICAID | 500634561 | 05 | OR |   | MEDICAID |