Provider Demographics
NPI:1033278866
Name:HARRIS, KAREN GAYE (DO)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:GAYE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GAYE
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S HAZEL DELL WAY
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-7829
Practice Address - Country:US
Practice Address - Phone:503-263-9500
Practice Address - Fax:503-263-1383
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR069232Medicaid
ORP00910531OtherRR MEDICARE
ORR152857Medicare PIN
ORR152856Medicare PIN
ORR152852Medicare PIN
ORR152854Medicare PIN
ORR152851Medicare PIN
ORP00910531OtherRR MEDICARE