Provider Demographics
NPI:1538128202
Name:MIURA, LISA NOELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:NOELLE
Last Name:MIURA
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 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1630
Mailing Address - Country:US
Mailing Address - Phone:503-413-4340
Mailing Address - Fax:503-413-1923
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-413-4340
Practice Address - Fax:503-413-1923
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21271207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287520Medicaid
OR110787Medicare ID - Type Unspecified
OR287520Medicaid