Provider Demographics
NPI:1316018864
Name:TIPPIN, MARY M (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:TIPPIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 MT. HOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071
Mailing Address - Country:US
Mailing Address - Phone:971-983-5252
Mailing Address - Fax:971-983-5253
Practice Address - Street 1:1475 MT. HOOD AVENUE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:971-983-5252
Practice Address - Fax:971-983-5253
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR094007047363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR071514Medicaid
ORNPP000Medicare UPIN
OR102137Medicare ID - Type Unspecified