Provider Demographics
NPI:1134520604
Name:PENDERGRAFT, PAUL (AUD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:PENDERGRAFT
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 NE 60TH AVE
Mailing Address - Street 2:APT A1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 NE 60TH AVE
Practice Address - Street 2:APT A1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3765
Practice Address - Country:US
Practice Address - Phone:336-339-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR030803231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist