Provider Demographics
NPI:1245770890
Name:WOLF CROW MEDICINE
Entity Type:Organization
Organization Name:WOLF CROW MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MS
Authorized Official - First Name:J
Authorized Official - Middle Name:WHISKEY
Authorized Official - Last Name:NORTHROP
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-701-6077
Mailing Address - Street 1:3265 NE HOLMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6758
Mailing Address - Country:US
Mailing Address - Phone:503-701-6077
Mailing Address - Fax:
Practice Address - Street 1:833 SE MAIN ST STE 308
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3427
Practice Address - Country:US
Practice Address - Phone:503-701-6077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC173827171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500704599Medicaid