Provider Demographics
NPI:1902096936
Name:MOLYNEUX, KATHERINE L J (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L J
Last Name:MOLYNEUX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17704 JEAN WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5497
Mailing Address - Country:US
Mailing Address - Phone:503-675-6776
Mailing Address - Fax:503-675-2572
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-675-6776
Practice Address - Fax:503-675-2572
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR181207Medicare PIN