Provider Demographics
NPI:1649384165
Name:WALL, KATHLEEN GORDON (PA-C)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:GORDON
Last Name:WALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5924 NE 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6132
Mailing Address - Country:US
Mailing Address - Phone:503-493-0546
Mailing Address - Fax:
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6055
Practice Address - Country:US
Practice Address - Phone:360-418-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003853363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical