Provider Demographics
NPI:1003030057
Name:COON, MICHAEL R (LPN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:COON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 NE KANE DR
Mailing Address - Street 2:APT 19
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-1515
Mailing Address - Country:US
Mailing Address - Phone:971-223-5777
Mailing Address - Fax:
Practice Address - Street 1:808 SW ALDER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3133
Practice Address - Country:US
Practice Address - Phone:503-226-2203
Practice Address - Fax:503-223-4231
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse