Provider Demographics
NPI:1043540669
Name:DODD, KRISTEN DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DAWN
Last Name:DODD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:DAWN
Other - Last Name:LENTELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:960 N 16TH ST STE 304
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4175
Mailing Address - Country:US
Mailing Address - Phone:541-744-6172
Mailing Address - Fax:541-744-8608
Practice Address - Street 1:960 N 16TH ST STE 207
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4175
Practice Address - Country:US
Practice Address - Phone:541-744-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR150610363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical