Basic Information
| Provider Information | |||||||||
| NPI: | 1255306205 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REAGAN | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2406 NE 19TH | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032872089 | ||||||||
| FaxNumber: | 5032362676 | ||||||||
| Practice Location | |||||||||
| Address1: | 541 NE 20TH AVE | ||||||||
| Address2: | SUITE210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032336940 | ||||||||
| FaxNumber: | 5032362676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 14470 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 49531 | 01 | WA | WA DEPT. OF L&I | OTHER | 8154130 | 05 | WA | MEDICAID | 162032 | 05 | OR | MEDICAID |