Provider Demographics
NPI:1124088448
Name:HERNANDEZ, CATHLEEN L (PA)
Entity type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:L
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6625
Mailing Address - Country:US
Mailing Address - Phone:503-297-1419
Mailing Address - Fax:503-216-2488
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-1419
Practice Address - Fax:503-216-2488
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17443363A00000X
ORPA01239363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PA174430Medicaid
WPA17743BMedicare ID - Type Unspecified
OR138662Medicare PIN
CAQ26877Medicare UPIN
CA00PA174430Medicaid