Provider Demographics
NPI:1083669410
Name:WHITE, AGNES (FNP, LAC)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:FNP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7787
Mailing Address - Country:US
Mailing Address - Phone:503-659-0880
Mailing Address - Fax:
Practice Address - Street 1:421 SW OAK ST
Practice Address - Street 2:STE. 210
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1817
Practice Address - Country:US
Practice Address - Phone:503-988-7468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR096000382N1363L00000X
ORAC150310171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR096511Medicaid
OR22959Medicaid
S54447Medicare UPIN