Provider Demographics
NPI:1316913387
Name:DOUGHERTY, LAURA DESIREE (PA)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:DESIREE
Last Name:DOUGHERTY
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 1:9775 SE SUNNYSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5724
Mailing Address - Country:US
Mailing Address - Phone:503-654-7546
Mailing Address - Fax:503-786-3542
Practice Address - Street 1:9775 SE SUNNYSIDE RD STE 500
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5724
Practice Address - Country:US
Practice Address - Phone:503-654-7546
Practice Address - Fax:503-786-3542
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19988363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19988OtherCALIFORNIA LICENSE