Provider Demographics
NPI:1922200286
Name:EDGEHOUSE, KRISTIN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:EDGEHOUSE
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-474-7500
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:SHMC 3 NORTH
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-7500
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60233214208000000X, 2080P0207X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1922200286OtherREGENCE BLUESHIELD
ID1922200286Medicaid
WA2014099Medicaid
IDS6646OtherBC/ID
WA028385OtherLABOR & INDUSTRIES
WAG8903815Medicare PIN
ID1922200286Medicaid