Basic Information
| Provider Information | |||||||||
| NPI: | 1457637860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOLESCU | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970588003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412987971 | ||||||||
| FaxNumber: | 5412966431 | ||||||||
| Practice Location | |||||||||
| Address1: | 551 LONE PINE BLVD STE 302 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970589404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066500 | ||||||||
| FaxNumber: | 5415066501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2011 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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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 | 363A00000X | PA4277 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA159795 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500654260 | 05 | OR | MEDICAID |