Healthcare Provider Details

I. General information

NPI: 1306036314
Provider Name (Legal Business Name): KRISTIN EMILY BERRY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN E WAGNER DO

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW 5TH ST
REDMOND OR
97756-1869
US

IV. Provider business mailing address

3640 NW SAMARITAN DR STE 270
CORVALLIS OR
97330-3784
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-6635
  • Fax: 541-526-6636
Mailing address:
  • Phone: 541-768-5300
  • Fax: 541-768-5251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101017373
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5315031830
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO156086
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: