Provider Demographics
NPI:1053548669
Name:PONSFORD, KATHLEEN RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RYAN
Last Name:PONSFORD
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:305 SE CHKALOV DR STE 170
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-787-7135
Practice Address - Fax:360-799-3913
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2018-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA60090604363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0252790OtherL & I
WAG8883432Medicare PIN