Provider Demographics
NPI:1841282357
Name:WINDOM, KRISTINE JOST (PAC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:JOST
Last Name:WINDOM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:JOST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-236-0775
Mailing Address - Fax:503-236-0786
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 440
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-3766
Practice Address - Fax:503-297-8148
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00978363AS0400X
WAPA10004840363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500602008Medicaid
OR500602008Medicaid
OR165790Medicare PIN
OR119341Medicare ID - Type Unspecified