Basic Information
| Provider Information | |||||||||
| NPI: | 1417326984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291253 | ||||||||
| FaxNumber: | 3607293185 | ||||||||
| Practice Location | |||||||||
| Address1: | 537 UNION AVE | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2015 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA174747 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.