Provider Demographics
NPI:1093204257
Name:MULATU, MISTIR
Entity Type:Individual
Prefix:
First Name:MISTIR
Middle Name:
Last Name:MULATU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTIER
Other - Middle Name:
Other - Last Name:MULATU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15065 SW OPAL DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-8770
Mailing Address - Country:US
Mailing Address - Phone:612-414-1984
Mailing Address - Fax:
Practice Address - Street 1:15065 SW OPAL DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-8770
Practice Address - Country:US
Practice Address - Phone:612-414-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X
MN156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty