Provider Demographics
NPI:1407820293
Name:EBERHARDT, KIRSTEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:B
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:320 WILLOW
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-525-5010
Practice Address - Fax:509-522-9448
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033172207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8193773Medicaid
OR084827Medicaid
WA109314OtherL&I
WAG44607Medicare UPIN
WA8193773Medicaid