Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | A100550 | CA |
N | 111NI0900X | Internist | A100550 | CA |
N | 207R00000X | Internist | MD172330 | OR |
N | 111NI0900X | Internist | MD172330 | OR |
Y | 207RN0300X | Nephrologist | MD172330 | OR |
NPI | 1033319199 |
---|---|
Provider Name | Pavan Kumar K Gona |
First Address | Corvallis, OR 97333 |
Second Address | Corvallis, OR 97333 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2007 |
Last Update Date | 27/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0A1005500 | (05) | CA |
A100550 | CA MEDICAL LICENSE (01) | CA |