Provider Demographics
NPI:1366497281
Name:CRABTREE, MARY KATHERINE (DNSC, ANP, PROFESSO)
Entity Type:Individual
Prefix:PROF
First Name:MARY
Middle Name:KATHERINE
Last Name:CRABTREE
Suffix:
Gender:F
Credentials:DNSC, ANP, PROFESSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13045 SW KATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1899
Mailing Address - Country:US
Mailing Address - Phone:503-590-9800
Mailing Address - Fax:
Practice Address - Street 1:4610 SE BELMONT ST
Practice Address - Street 2:SUITE 60
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1752
Practice Address - Country:US
Practice Address - Phone:503-988-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022662Medicaid
OR120137Medicare ID - Type Unspecified
OR022662Medicaid