Basic Information
| Provider Information | |||||||||
| NPI: | 1114179116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOTSON | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | MARIE MCNICHOLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCNICHOLAS | ||||||||
| OtherFirstName: | MALLORY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10000 SE MAIN ST | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032553054 | ||||||||
| FaxNumber: | 5032557651 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 SE MAIN ST | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032553054 | ||||||||
| FaxNumber: | 5032557651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA1405 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA1405 | 01 | OR | LICENCE | OTHER |