Provider Demographics
NPI:1629129523
Name:COLLETTO, KRIS (MD)
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:
Last Name:COLLETTO
Suffix:
Gender:F
Credentials:MD
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:3400 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2223
Practice Address - Country:US
Practice Address - Phone:360-696-5232
Practice Address - Fax:360-696-5228
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039202207PE0004X, 207R00000X
WABC5836032208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8269276Medicaid
WA8269276Medicaid
WAG8865305Medicare PIN
WAG8872282Medicare PIN
WAG8871505Medicare PIN