Provider Demographics
NPI:1417326984
Name:WALLACE, KRISTINA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1253
Mailing Address - Fax:360-729-3185
Practice Address - Street 1:537 UNION AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5543
Practice Address - Country:US
Practice Address - Phone:541-479-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA174747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant