Provider Demographics
NPI:1508897778
Name:MOON, KATHRYN KOLB (MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:KOLB
Last Name:MOON
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:FAMILY MEDICINE
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4574
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:UROLOGY
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4574
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200442251RN363L00000X
OR200450152NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292415Medicaid
ORR0000WFBTVOtherNORTH BEND MEDICAL CENTER GROUP MEDICARE
OR161133OtherNORTH BEND MEDICAL CENTER GROUP MEDICAID
OR93-0635514OtherNORTH BEND MEDICAL CENTER GROUP TAX ID
OR1407812365OtherNORTH BEND MEDICAL CENTER GROUP NPI
ORP01673840OtherPALMETTO GBA - RAILROAD
OR161133OtherNORTH BEND MEDICAL CENTER GROUP MEDICAID