Healthcare Provider Details

I. General information

NPI: 1992218838
Provider Name (Legal Business Name): KRISTEN MASSING WILSON PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4531 SE BELMONT ST STE 100
PORTLAND OR
97215-1675
US

IV. Provider business mailing address

4531 SE BELMONT ST STE 100
PORTLAND OR
97215-1675
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-5973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number48118
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number14188
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: