Healthcare Provider Details

I. General information

NPI: 1629123302
Provider Name (Legal Business Name): KATHLEEN S PICKERING PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 E 12TH ST
THE DALLES OR
97058
US

IV. Provider business mailing address

1750 12TH ST
HOOD RIVER OR
97031-9540
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-9151
  • Fax: 541-296-4710
Mailing address:
  • Phone: 541-386-5070
  • Fax: 541-386-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01211
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number469
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: