Healthcare Provider Details

I. General information

NPI: 1417042854
Provider Name (Legal Business Name): KATHRYN F MCGONIGLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 NW 22ND AVE
PORTLAND OR
97210-3025
US

IV. Provider business mailing address

1015 NW 22ND AVE
PORTLAND OR
97210-3025
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-8654
  • Fax: 503-413-8655
Mailing address:
  • Phone: 503-413-8654
  • Fax: 503-413-8655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number743
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD204288
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD00040252
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: