Provider Demographics
NPI:1275081184
Name:KOLKOW, PALOMA SITA
Entity Type:Individual
Prefix:
First Name:PALOMA
Middle Name:SITA
Last Name:KOLKOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PALOMA
Other - Middle Name:SITA
Other - Last Name:SYATAUW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1051
Mailing Address - Country:US
Mailing Address - Phone:541-471-3455
Mailing Address - Fax:541-471-9242
Practice Address - Street 1:1701 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1051
Practice Address - Country:US
Practice Address - Phone:541-471-3455
Practice Address - Fax:541-471-9242
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201607773NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500715478Medicaid
OR500715478Medicaid