Provider Demographics
NPI:1407849631
Name:PORTER, MARY PATRICIA SAUER (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA SAUER
Last Name:PORTER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARY PAT
Other - Middle Name:
Other - Last Name:SAUER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-226-6321
Practice Address - Fax:503-227-3422
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00633363AS0400X
WAPA10003796363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR021589Medicaid
WA8435737Medicaid
WA838459Medicare PIN
ORS77429Medicare UPIN
OR116076Medicare ID - Type UnspecifiedPORTLAND
WAAB38459Medicare ID - Type UnspecifiedVANCOUVER
OR021589Medicaid
WA8435737Medicaid