Provider Demographics
NPI:1316565708
Name:HINES-KRUSE, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HINES-KRUSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1506 W HIGHLINE LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-1911
Mailing Address - Country:US
Mailing Address - Phone:623-308-4704
Mailing Address - Fax:
Practice Address - Street 1:210 W MAIN AVE
Practice Address - Street 2:
Practice Address - City:RITZVILLE
Practice Address - State:WA
Practice Address - Zip Code:99169-1410
Practice Address - Country:US
Practice Address - Phone:509-659-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-11
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61096605207Q00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine