Provider Demographics
NPI:1639123300
Name:WHITTAM, KARLI (MO)
Entity Type:Individual
Prefix:DR
First Name:KARLI
Middle Name:
Last Name:WHITTAM
Suffix:
Gender:F
Credentials:MO
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 2077
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2077
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:
Practice Address - Street 1:1000 SE TECH CENTER DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-260-2773
Practice Address - Fax:360-260-2217
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMO00035092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8226359Medicaid
WA8226359Medicaid
G32009Medicare UPIN