Provider Demographics
NPI:1003286360
Name:RODENBURG, KATHLEEN IRENE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:IRENE
Last Name:RODENBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:IRENE
Other - Last Name:STRAHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:11782 SW BARNES RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5933
Mailing Address - Country:US
Mailing Address - Phone:503-214-5520
Mailing Address - Fax:503-906-6613
Practice Address - Street 1:11782 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5933
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:503-906-6613
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA205646363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA205646OtherPA LICENSE