Provider Demographics
NPI:1235353863
Name:PROCTOR, KERRY ANNE SCULLY (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ANNE SCULLY
Last Name:PROCTOR
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 1:1700 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3317
Mailing Address - Country:US
Mailing Address - Phone:541-296-1111
Mailing Address - Fax:
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36695207ZP0102X
UT5223915-1205207ZP0102X
ORMD27633207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8494999Medicaid
ORR0000ZBBWZOtherMEDICARE GROUP NO
OR139526Medicare PIN