Provider Demographics
NPI:1679581714
Name:MCDONALD, MARY REGIS (PMHNP, FNP, CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:REGIS
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:PMHNP, FNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-657-1071
Mailing Address - Fax:503-657-3321
Practice Address - Street 1:9701 SW BARNES RD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6689
Practice Address - Country:US
Practice Address - Phone:503-734-3700
Practice Address - Fax:503-473-8462
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250134NP363LF0000X, 363LP0808X
OR202011103NP-PP363LP0808X
OR200550173NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232035Medicaid
ORR172911OtherMEDICARE PTAN