Provider Demographics
NPI:1467646711
Name:BARGOVAN, CATHERINE I (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:I
Last Name:BARGOVAN
Suffix:
Gender:F
Credentials:PA-C
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:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1321 NE 99TH AVE
Practice Address - Street 2:STE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9434
Practice Address - Country:US
Practice Address - Phone:503-215-9900
Practice Address - Fax:503-215-4025
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005028363A00000X
ORPA01456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616510Medicaid
ORP01028698OtherRR MEDICARE - PROVIDENCE
ORR161935Medicare PIN
ORR161937Medicare PIN
MI0N33470Medicare PIN
ORR161933Medicare PIN
ORR161932Medicare PIN
ORR161934Medicare PIN
ORR161936Medicare PIN