Provider Demographics
NPI:1659988814
Name:KILDOW, TRISTA (PSS/THW/CRM)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:KILDOW
Suffix:
Gender:F
Credentials:PSS/THW/CRM
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 16576
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0576
Mailing Address - Country:US
Mailing Address - Phone:503-465-2749
Mailing Address - Fax:503-208-2596
Practice Address - Street 1:900 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1869
Practice Address - Country:US
Practice Address - Phone:503-465-2749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000003403175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist