Provider Demographics
NPI:1568419091
Name:CONCIA, CAROLYN DOLORES (NP)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:DOLORES
Last Name:CONCIA
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 1:2308 NW STIMPSON LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8562
Mailing Address - Country:US
Mailing Address - Phone:919-561-0140
Mailing Address - Fax:
Practice Address - Street 1:2308 NW STIMPSON LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-8562
Practice Address - Country:US
Practice Address - Phone:919-561-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099007642N4363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR289362Medicaid
OR067593012OtherBLUE CROSS BLUE SHIELD
OR289362Medicaid
OR067593012OtherBLUE CROSS BLUE SHIELD