Provider Demographics
NPI:1083488480
Name:PADRTA, MICHAEL JOHN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:PADRTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12540 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6198
Mailing Address - Country:US
Mailing Address - Phone:503-906-9995
Mailing Address - Fax:
Practice Address - Street 1:12512 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1070
Practice Address - Country:US
Practice Address - Phone:503-906-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist