Provider Demographics
NPI:1184606733
Name:RAETZ, KATHLEEN M (CNM)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:RAETZ
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 SW BARNES RD
Mailing Address - Street 2:SUITE 299
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-734-3700
Mailing Address - Fax:503-473-8462
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 299
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-734-3700
Practice Address - Fax:503-473-8462
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000028920N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR124169Medicaid
OR106583Medicare ID - Type Unspecified
OR124169Medicaid