Provider Demographics
NPI:1083681860
Name:AHLEN, PATRICIA PARK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:PARK
Last Name:AHLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 MARCOLA ROAD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-2594
Mailing Address - Country:US
Mailing Address - Phone:541-747-4300
Mailing Address - Fax:541-747-0655
Practice Address - Street 1:2280 MARCOLA ROAD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2594
Practice Address - Country:US
Practice Address - Phone:541-747-4300
Practice Address - Fax:541-747-0655
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004267Medicaid
OR004267Medicaid
C94243Medicare UPIN