Provider Demographics
NPI:1376164145
Name:MCCLUSKEY, MOLLY CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MOLLY
Middle Name:CHRISTINE
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:130
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224
Mailing Address - Country:US
Mailing Address - Phone:503-603-9087
Mailing Address - Fax:503-603-9122
Practice Address - Street 1:16083 SW UPPER BOONES FERRY RD
Practice Address - Street 2:130
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224
Practice Address - Country:US
Practice Address - Phone:503-603-9087
Practice Address - Fax:503-603-9122
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA207464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program