Healthcare Provider Details

I. General information

NPI: 1932560448
Provider Name (Legal Business Name): KATHLEEN RAFTERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MOTHER JOSEPH PL STE 330
VANCOUVER WA
98664-3288
US

IV. Provider business mailing address

4438 HIDEAWAY PL
LA MESA CA
91941-6800
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2990
  • Fax: 360-514-3508
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61285554
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMED-PAC-REG-0001782
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMED-PAC-LIC-91166
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: