Provider Demographics
NPI:1639983133
Name:MARTIN, KRISTIN SHANDEL (NP)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:SHANDEL
Last Name:MARTIN
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:SHANDEL
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15640 NW LAIDLAW RD STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-3828
Practice Address - Country:US
Practice Address - Phone:503-956-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10035209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily