Provider Demographics
NPI:1285024174
Name:HART, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 MCGEE CT NE
Mailing Address - Street 2:APT 204
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-9470
Mailing Address - Country:US
Mailing Address - Phone:503-983-4898
Mailing Address - Fax:
Practice Address - Street 1:4890 32ND AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9350
Practice Address - Country:US
Practice Address - Phone:503-588-5647
Practice Address - Fax:503-588-0509
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7624358172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker