Provider Demographics
NPI:1265836605
Name:BOSTON, IRIS S (PMHNP)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:S
Last Name:BOSTON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:971-386-2278
Mailing Address - Fax:503-224-4494
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201243237RN163W00000X
WARN61337493163W00000X
WAAP61337497363L00000X
OR201405678NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2075287Medicaid
OR500683308Medicaid