Provider Demographics
NPI:1235113366
Name:GLIVINSKI, MINDY ERIN (PA)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:ERIN
Last Name:GLIVINSKI
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 1:875 OAK ST SE
Mailing Address - Street 2:STE 3010
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-399-7520
Mailing Address - Fax:503-362-7344
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:STE 3010
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-399-7520
Practice Address - Fax:503-362-7344
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01018363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023015Medicaid