Basic Information
| Provider Information | |||||||||
| NPI: | 1568650828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAUER | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039632825 | ||||||||
| Practice Location | |||||||||
| Address1: | 19250 SW 65TH AVE | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970627452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036924820 | ||||||||
| FaxNumber: | 5036120793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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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 | 363AS0400X | 011967 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA150681 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 500602008 | 05 | OR | MEDICAID |