Provider Demographics
NPI:1336110469
Name:NORTH, PHOENIX SENNA (MD)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:SENNA
Last Name:NORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WELCH ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1946
Mailing Address - Country:US
Mailing Address - Phone:503-874-6026
Mailing Address - Fax:
Practice Address - Street 1:530 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1946
Practice Address - Country:US
Practice Address - Phone:503-874-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274363Medicaid
OR274363Medicaid