Provider Demographics
NPI: | 1003471491 |
---|---|
Name: | PURVIS, MICHAEL EDWARD (PAC) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | EDWARD |
Last Name: | PURVIS |
Suffix: | |
Gender: | M |
Credentials: | PAC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 541 NE 20TH AVE STE 225 |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97232-2895 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-963-2801 |
Mailing Address - Fax: | 503-963-2825 |
Practice Address - Street 1: | 9155 SW BARNES RD STE 440 |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97225-6631 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-935-8500 |
Practice Address - Fax: | 503-935-8505 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2019-05-01 |
Last Update Date: | 2023-11-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | PA202232 | 363AS0400X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 500787174 | Medicaid |