MEDICARE: MS. MARY C REGAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA196072	OR
2	363AM0700X	Medical Physician Assistant
3	207Q00000X	Family Medicine Physician	APA14888	CA

General Provider Information

NPI Number	:	1740276344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY C REGAN PA-C

Provider Business Mailing Address
First Line	:	51377 SW OLD PORTLAND RD
Second Line	:
City	:	SCAPPOOSE
State	:	OR
Zip	:	97056-4023
Country	:	US
Telephone Number	:	503-418-4222
Fax Number	:	503-418-4223

Provider Business Practice Location Address
First Line	:	51377 SW OLD PORTLAND RD
Second Line	:
City	:	SCAPPOOSE
State	:	OR
Zip	:	97056-4023
Country	:	US
Telephone Number	:	503-418-4222
Fax Number	:	503-418-4223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	12/29/2020

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