Provider Demographics
NPI:1750374021
Name:SIEBE, KATHLEEN (PNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SIEBE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 MEDICAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1168
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:541-426-6403
Practice Address - Street 1:603 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1168
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:541-426-6403
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR78040158363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5966003OtherBCBS
ORJ054904OtherPACIFIC SOURCE
OR267989Medicaid
OR267989Medicaid
OR1103330001Medicare NSC
ORJ054904OtherPACIFIC SOURCE