Provider Demographics
NPI:1730495599
Name:DAUGHERTY, MONICA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:MARIE
Last Name:DAUGHERTY
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 1:1515 NW 18TH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2539
Mailing Address - Country:US
Mailing Address - Phone:503-224-8399
Mailing Address - Fax:503-224-5661
Practice Address - Street 1:4103 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2556
Practice Address - Country:US
Practice Address - Phone:503-850-9940
Practice Address - Fax:503-850-6709
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA152606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant