Basic Information
| Provider Information | |||||||||
| NPI: | 1679581714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | REGIS | ||||||||
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| Credential: | PMHNP, FNP, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036571071 | ||||||||
| FaxNumber: | 5036573321 | ||||||||
| Practice Location | |||||||||
| Address1: | 9701 SW BARNES RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037343700 | ||||||||
| FaxNumber: | 5034738462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200250134NP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 202011103NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 367A00000X | 200550173NP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LP0808X | 200250134NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 232035 | 05 | OR | MEDICAID |