Provider Demographics
NPI:1124361241
Name:MOON, KRISTINA BRITTANY (DO)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:BRITTANY
Last Name:MOON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:BRITTANY
Other - Last Name:CUMMINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:1001 N PROVIDENCE DR STE 325
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7485
Practice Address - Country:US
Practice Address - Phone:503-537-6026
Practice Address - Fax:503-537-6027
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011889207R00000X
WI67012-21207RC0000X
ORDO198364207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine