Provider Demographics
NPI:1982174199
Name:MARTIN, KRISTYN L (NP)
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTYN
Other - Middle Name:L
Other - Last Name:STAAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-452-8000
Mailing Address - Fax:208-452-8055
Practice Address - Street 1:910 NW 16TH ST STE 101
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2265
Practice Address - Country:US
Practice Address - Phone:208-452-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201810671NP-PP363L00000X
ID60199363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201810671NP-PPOtherOREGON STATE BOARD OF NURSING