Provider Demographics
NPI:1174602247
Name:MCPHERSON, KATRINA (MD)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:MCPHERSON
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 1:2265 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3331
Mailing Address - Country:US
Mailing Address - Phone:503-325-4321
Mailing Address - Fax:503-325-4905
Practice Address - Street 1:1825 MAPLE ST
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1939
Practice Address - Country:US
Practice Address - Phone:503-357-2136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89509208000000X
ORMD29316261Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269803000Medicaid
OR1134146939Medicaid