Basic Information
| Provider Information | |||||||||
| NPI: | 1780036293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBBENNOLT | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 S 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989023550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094946700 | ||||||||
| FaxNumber: | 5098531082 | ||||||||
| Practice Location | |||||||||
| Address1: | 521 E MOUNTAIN VIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ELLENSBURG | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989263865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099621414 | ||||||||
| FaxNumber: | 5094525224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2016 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OL60861783 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OP61072638 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2102026 | 05 | WA | MEDICAID |