Basic Information
| Provider Information | |||||||||
| NPI: | 1841282357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINDOM | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | JOST | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOST | ||||||||
| OtherFirstName: | KRISTINE | ||||||||
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| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 975 SE SANDY BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032360775 | ||||||||
| FaxNumber: | 5032360786 | ||||||||
| Practice Location | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032973766 | ||||||||
| FaxNumber: | 5032978148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA00978 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA10004840 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 500602008 | 05 | OR | MEDICAID |