Provider Demographics
NPI:1245414978
Name:BAWDEN, GINA MARJORIE (PAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARJORIE
Last Name:BAWDEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:2850 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1494
Practice Address - Country:US
Practice Address - Phone:503-666-5050
Practice Address - Fax:503-666-1162
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22873363A00000X
ORPA01337363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500604977Medicaid
WA8504961Medicaid
OR140621Medicare PIN
OR147131Medicare PIN