Healthcare Provider Details

I. General information

NPI: 1760436372
Provider Name (Legal Business Name): ALICJA KATARZYNA GONZALES PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 NW 13TH AVE SUITE 300
PORTLAND OR
97209-2953
US

IV. Provider business mailing address

3600 NW JOHN OLSEN PL SUITE 250
HILLSBORO OR
97124-5815
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-4078
  • Fax: 186-685-9819
Mailing address:
  • Phone: 503-684-8252
  • Fax: 186-685-9819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01067
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: