Provider Demographics
NPI:1023000387
Name:HUYSSOON, KATHRYN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:L
Last Name:HUYSSOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24988 SE STARK ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8322
Mailing Address - Country:US
Mailing Address - Phone:503-674-5818
Mailing Address - Fax:503-674-6709
Practice Address - Street 1:24988 SE STARK ST
Practice Address - Street 2:STE 300
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8322
Practice Address - Country:US
Practice Address - Phone:503-674-5818
Practice Address - Fax:503-674-6709
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080697Medicaid
G30301Medicare UPIN
OR104632Medicare ID - Type Unspecified
OR080697Medicaid