Provider Demographics
NPI:1811463250
Name:MWANGA, CAITLIN M (PA)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:M
Last Name:MWANGA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:M
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:4004 KRUSE WAY PL STE 300
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2479
Practice Address - Country:US
Practice Address - Phone:503-216-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA190113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant