Healthcare Provider Details

I. General information

NPI: 1457637860
Provider Name (Legal Business Name): KRISTEN ELISE NICOLESCU PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2011
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 LONE PINE BLVD STE 302
THE DALLES OR
97058-9404
US

IV. Provider business mailing address

PO BOX 1520
THE DALLES OR
97058-8003
US

V. Phone/Fax

Practice location:
  • Phone: 541-506-6500
  • Fax: 541-506-6501
Mailing address:
  • Phone: 541-298-7971
  • Fax: 541-296-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4277
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA159795
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: