Healthcare Provider Details

I. General information

NPI: 1841282357
Provider Name (Legal Business Name): KRISTINE JOST WINDOM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINE JOST PAC

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD SUITE 440
PORTLAND OR
97225-6625
US

IV. Provider business mailing address

975 SE SANDY BLVD SUITE 201
PORTLAND OR
97214-1308
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-3766
  • Fax: 503-297-8148
Mailing address:
  • Phone: 503-236-0775
  • Fax: 503-236-0786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00978
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10004840
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: