Provider Demographics
NPI:1265640833
Name:MULCONREY, DONALD L (PA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:MULCONREY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9155 SW BARNES RD STE 210
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6629
Mailing Address - Country:US
Mailing Address - Phone:503-546-3503
Mailing Address - Fax:503-546-3507
Practice Address - Street 1:9155 SW BARNES RD STE 210
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6629
Practice Address - Country:US
Practice Address - Phone:503-546-3503
Practice Address - Fax:503-546-3507
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01224207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR137475Medicare PIN