Provider Demographics
NPI:1528031812
Name:DIMMLER, LAWANDA LYNN SR (PA-C)
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:LYNN
Last Name:DIMMLER
Suffix:SR
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST STE 610
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2985
Practice Address - Country:US
Practice Address - Phone:503-467-4761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1528031812Medicaid
OR500606835Medicaid
OR165622Medicare PIN
ORR136814Medicare PIN
WA1528031812Medicaid
ORP01196991Medicare PIN