Healthcare Provider Details

I. General information

NPI: 1740764943
Provider Name (Legal Business Name): KRISTEN KELLOGG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 NW CANAL BLVD
REDMOND OR
97756-1334
US

IV. Provider business mailing address

3340 HEMLOCK PL
BOULDER CO
80304-2355
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-8131
  • Fax: 541-526-6608
Mailing address:
  • Phone: 713-502-8021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0008907
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0008907
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: