Basic Information
| Provider Information | |||||||||
| NPI: | 1508897778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | KOLB | ||||||||
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| Credential: | M.S.N., F.N.P-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | FAMILY MEDICINE | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664574 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | UROLOGY | ||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/08/2016 | ||||||||
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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 | 363L00000X | 200442251RN | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 200450152NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 292415 | 05 | OR | MEDICAID | R0000WFBTV | 01 | OR | NORTH BEND MEDICAL CENTER GROUP MEDICARE | OTHER | 161133 | 01 | OR | NORTH BEND MEDICAL CENTER GROUP MEDICAID | OTHER | 93-0635514 | 01 | OR | NORTH BEND MEDICAL CENTER GROUP TAX ID | OTHER | 1407812365 | 01 | OR | NORTH BEND MEDICAL CENTER GROUP NPI | OTHER | P01673840 | 01 | OR | PALMETTO GBA - RAILROAD | OTHER |