Basic Information
| Provider Information | |||||||||
| NPI: | 1629123302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKERING | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1750 12TH ST | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970319540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413865070 | ||||||||
| FaxNumber: | 5413867190 | ||||||||
| Practice Location | |||||||||
| Address1: | 1620 E 12TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412969151 | ||||||||
| FaxNumber: | 5412964710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 11/03/2017 | ||||||||
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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 | 363A00000X | PA01211 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 469 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 218112 | 05 | OR | MEDICAID |