Basic Information
Provider Information | |||||||||
NPI: | 1326099672 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JARSTAD | ||||||||
FirstName: | KATIE | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KLEIN | ||||||||
OtherFirstName: | KATIE | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1593 E POLSTON AVE | ||||||||
Address2: |   | ||||||||
City: | POST FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 838545326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082622300 | ||||||||
FaxNumber: | 2082622390 | ||||||||
Practice Location | |||||||||
Address1: | 315 W DALTON AVE STE B | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838158600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082092066 | ||||||||
FaxNumber: | 2082092076 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 08/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-580 | ID | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA-580 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1326099672 | 05 | ID |   | MEDICAID |