Provider Demographics
NPI:1255328290
Name:BARTHOLOMEW, KELLY MAHARA (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MAHARA
Last Name:BARTHOLOMEW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MAHARA
Other - Last Name:CHARLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2230 NW PETTYGROVE
Mailing Address - Street 2:#210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-223-6223
Mailing Address - Fax:503-223-3665
Practice Address - Street 1:2226 NW PETTYGROVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-223-6223
Practice Address - Fax:503-223-3665
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA00693Medicaid
ORPA00693Medicaid