Provider Demographics
NPI:1730212234
Name:VON, MARY ELIZABETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:VON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:RATZLAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4170 NW CARLTON CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-2946
Mailing Address - Country:US
Mailing Address - Phone:503-927-4427
Mailing Address - Fax:
Practice Address - Street 1:222 SE 8TH AVE
Practice Address - Street 2:SUITE 551
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4218
Practice Address - Country:US
Practice Address - Phone:503-352-7308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant