Provider Demographics
NPI:1396784062
Name:MOORE, KATHLEEN BAKER (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:BAKER
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4800
Mailing Address - Street 2:UNIT 17
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4800
Mailing Address - Country:US
Mailing Address - Phone:888-633-0087
Mailing Address - Fax:
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24465207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8120099Medicaid
200126OtherWA L & I
OR227377Medicaid
P00242572OtherRAILROAD
CAXPY206683Medicaid
8906937OtherWA CRIME VICTIMS
8906937OtherWA CRIME VICTIMS
WA8120099Medicaid