Provider Demographics
NPI:1083088074
Name:POPPA, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:POPPA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JANE
Other - Middle Name:MARIE
Other - Last Name:POPPA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4437 ANTELOPE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-1867
Mailing Address - Country:US
Mailing Address - Phone:541-951-7086
Mailing Address - Fax:
Practice Address - Street 1:140 S HOLLY ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3113
Practice Address - Country:US
Practice Address - Phone:541-774-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator