Provider Demographics
NPI:1194918409
Name:HOLMES, KIRSTEN A (PA-C)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:A
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:101 NW 12TH AVE
Practice Address - Street 2:STE 107
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-9141
Practice Address - Country:US
Practice Address - Phone:360-687-6650
Practice Address - Fax:360-514-6820
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00532363A00000X
WAPA10003545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1194918409Medicaid
OR500634561Medicaid