Basic Information
Provider Information | |||||||||
NPI: | 1821315912 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BERGLUND | ||||||||
FirstName: | KATE | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CORRIGAN | ||||||||
OtherFirstName: | KATE | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3158 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972083158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032156494 | ||||||||
FaxNumber: | 5032156644 | ||||||||
Practice Location | |||||||||
Address1: | 5050 NE HOYT ST | ||||||||
Address2: | SUITE 511 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972132991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039621020 | ||||||||
FaxNumber: | 5039621021 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2010 | ||||||||
LastUpdateDate: | 02/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA156507 | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA156507 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 500639509 | 05 | OR |   | MEDICAID | 1821315912 | 05 | WA |   | MEDICAID | P01238740 | 01 | OR | RR MEDICARE - PROVIDENCE | OTHER |