Basic Information
| Provider Information | |||||||||
| NPI: | 1184606733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAETZ | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9701 SW BARNES RD | ||||||||
| Address2: | SUITE 299 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037343700 | ||||||||
| FaxNumber: | 5034738462 | ||||||||
| Practice Location | |||||||||
| Address1: | 9701 SW BARNES RD | ||||||||
| Address2: | SUITE 299 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037343700 | ||||||||
| FaxNumber: | 5034738462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 03/01/2010 | ||||||||
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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 | 367A00000X | 000028920N5 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 124169 | 05 | OR | MEDICAID |