Provider Demographics
NPI:1336103944
Name:WATHEN, MARY C (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WATHEN
Suffix:
Gender:F
Credentials:ARNP, CNM
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 3158
Mailing Address - Street 2:ATTN: CREDENTIALING
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 1:9427 SW BARNES RD
Practice Address - Street 2:SUITE 395
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-2602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004769363L00000X, 367A00000X
OR201150146NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263673OtherLABOR & INDUSTRIES
OR500682873Medicaid
WA9630179Medicaid
ORR180313Medicare PIN
ORR180314Medicare PIN
OR500682873Medicaid
WAG8892970Medicare PIN
WA263673OtherLABOR & INDUSTRIES
ORR180315Medicare PIN