Provider Demographics
NPI:1740276344
Name:REGAN, MARY C (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:REGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51377 SW OLD PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-4023
Mailing Address - Country:US
Mailing Address - Phone:503-418-4222
Mailing Address - Fax:503-418-4223
Practice Address - Street 1:51377 SW OLD PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4023
Practice Address - Country:US
Practice Address - Phone:503-418-4222
Practice Address - Fax:503-418-4223
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA196072363A00000X
363AM0700X
CAAPA14888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA144370Medicare ID - Type Unspecified
A45811Medicare UPIN