Provider Demographics
NPI:1457637860
Name:NICOLESCU, KRISTEN ELISE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELISE
Last Name:NICOLESCU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8003
Mailing Address - Country:US
Mailing Address - Phone:541-298-7971
Mailing Address - Fax:541-296-6431
Practice Address - Street 1:551 LONE PINE BLVD STE 302
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-9404
Practice Address - Country:US
Practice Address - Phone:541-506-6500
Practice Address - Fax:541-506-6501
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4277363A00000X
ORPA159795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500654260Medicaid
ORR169547Medicare PIN