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
State | License ID | Taxonomies |
---|---|---|
OR | 78040158 | 363LP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 5966003 | Other | BCBS |
OR | J054904 | Other | PACIFIC SOURCE |
OR | 267989 | Medicaid | |
OR | 267989 | Medicaid | |
OR | 1103330001 | Medicare NSC | |
OR | J054904 | Other | PACIFIC SOURCE |