Healthcare Provider Details

I. General information

NPI: 1932497518
Provider Name (Legal Business Name): CHRISTINA DOUGHTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST SUITE 110
GRESHAM OR
97030-3373
US

IV. Provider business mailing address

1611 S LAMAR ST
ANAHEIM CA
92804-6042
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5388
  • Fax: 503-666-9393
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number21575
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA166318
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: