Provider Demographics
NPI:1144230285
Name:FLEURY, PHILIP A (ANP)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:A
Last Name:FLEURY
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 NE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4833
Mailing Address - Country:US
Mailing Address - Phone:503-287-7472
Mailing Address - Fax:
Practice Address - Street 1:4610 SE BELMONT
Practice Address - Street 2:SUITE 60
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215
Practice Address - Country:US
Practice Address - Phone:503-988-5303
Practice Address - Fax:503-988-5112
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR081001212N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067959Medicaid
OR109761Medicare ID - Type Unspecified
P34339Medicare UPIN