Healthcare Provider Details

I. General information

NPI: 1639749138
Provider Name (Legal Business Name): KATHARINE GRACE PORTER GAVIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 STONY CIR STE 1600
SANTA ROSA CA
95401-9520
US

IV. Provider business mailing address

131 STONY CIR STE 1600
SANTA ROSA CA
95401-9520
US

V. Phone/Fax

Practice location:
  • Phone: 707-541-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A22994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: