Provider Demographics
NPI:1114179116
Name:DOTSON, MALLORY MARIE MCNICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE MCNICHOLAS
Last Name:DOTSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:MARIE
Other - Last Name:MCNICHOLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-255-3054
Mailing Address - Fax:503-255-7651
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 112
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-255-3054
Practice Address - Fax:503-255-7651
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA1405363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA1405OtherLICENCE
ORPA1405OtherLICENCE