Basic Information
| Provider Information | |||||||||
| NPI: | 1275633174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPOON | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075296616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2829 GREAT NORTHERN LOOP STE 300 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065417000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | 49276 | MT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 352638000 | 05 | MN | MEDICAID | P00918779 | 01 | MN | RAILROAD MEDICARE | OTHER |