Provider Demographics
NPI:1972892693
Name:MEDWAR, KATHLEEN M (FNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:MEDWAR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:MEDWAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-7772
Mailing Address - Fax:503-418-3283
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7772
Practice Address - Fax:503-418-3283
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2263944363LF0000X
OR201350062NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0000023532OtherBMC
MA1004745OtherNHP
MA1303287OtherMBHP
MA042611055OtherTAX ID
OR500679358Medicaid
MA99618201OtherNETWORK HEALTH
MA1303287Medicaid
MAM18633OtherBCBS
MAY10074Medicare PIN