Provider Demographics
NPI:1174800031
Name:FARRELL, CAROLYN FRANCES (PA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:FRANCES
Last Name:FARRELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1682
Mailing Address - Country:US
Mailing Address - Phone:503-413-4488
Mailing Address - Fax:
Practice Address - Street 1:450 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1682
Practice Address - Country:US
Practice Address - Phone:503-413-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA169154363AS0400X
WAPA60320459363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical