Basic Information
| Provider Information | |||||||||
| NPI: | 1659988814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILDOW | ||||||||
| FirstName: | TRISTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSS/THW/CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16576 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034652749 | ||||||||
| FaxNumber: | 5032082596 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034652749 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | THW000003403 | OR | Y |
No ID Information.