Provider Demographics
NPI:1346676186
Name:DWYHALO, KRISTINA MARIE (MSPA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARIE
Last Name:DWYHALO
Suffix:
Gender:F
Credentials:MSPA
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPA
Mailing Address - Street 1:9900 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9777
Mailing Address - Country:US
Mailing Address - Phone:503-571-3495
Mailing Address - Fax:
Practice Address - Street 1:9900 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9777
Practice Address - Country:US
Practice Address - Phone:503-571-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA170407363A00000X
WAPA60514736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ857733Medicaid