Provider Demographics
NPI:1568650828
Name:MAUER, KRISTIN KATHLEEN (PA C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KATHLEEN
Last Name:MAUER
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:SUITE 235
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7452
Practice Address - Country:US
Practice Address - Phone:503-692-4820
Practice Address - Fax:503-612-0793
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011967363AS0400X
ORPA150681363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500602008Medicaid
ORP01677345Medicare PIN
OR181232Medicare PIN