1255328290 NPI number — KELLY MAHARA BARTHOLOMEW PA-C

Table of content: KELLY MAHARA BARTHOLOMEW PA-C (NPI 1255328290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255328290 NPI number — KELLY MAHARA BARTHOLOMEW PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARTHOLOMEW
Provider First Name:
KELLY
Provider Middle Name:
MAHARA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHARLES
Provider Other First Name:
KELLY
Provider Other Middle Name:
MAHARA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255328290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 NW PETTYGROVE
Provider Second Line Business Mailing Address:
#210
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-223-6223
Provider Business Mailing Address Fax Number:
503-223-3665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2226 NW PETTYGROVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-223-6223
Provider Business Practice Location Address Fax Number:
503-223-3665
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA00693 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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