Provider Demographics
NPI:1629123302
Name:PICKERING, KATHLEEN S (PAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:PICKERING
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-9540
Mailing Address - Country:US
Mailing Address - Phone:541-386-5070
Mailing Address - Fax:541-386-7190
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-9151
Practice Address - Fax:541-296-4710
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01211363A00000X
AK469363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218112Medicaid
OR383966Medicare Oscar/Certification
OR383997Medicare Oscar/Certification