Provider Demographics
NPI:1134179872
Name:KILPATRICK, PAULA DIANE
Entity type:Individual
Prefix:DR
First Name:PAULA
Middle Name:DIANE
Last Name:KILPATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 SW MERCANTILE DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2587
Mailing Address - Country:US
Mailing Address - Phone:503-697-3001
Mailing Address - Fax:503-697-0906
Practice Address - Street 1:4035 SW MERCANTILE DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2587
Practice Address - Country:US
Practice Address - Phone:503-697-3001
Practice Address - Fax:503-697-0906
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14112207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR173674Medicaid
OR173674Medicaid
C93043Medicare UPIN