Provider Demographics
NPI:1609876242
Name:MINCHOW, DEBRA J (ADULT/GERIATRIC NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:MINCHOW
Suffix:
Gender:F
Credentials:ADULT/GERIATRIC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 NE WEST DEVILS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-5131
Mailing Address - Country:US
Mailing Address - Phone:541-994-5591
Mailing Address - Fax:541-996-7294
Practice Address - Street 1:1010 SW COAST HWY STE 201
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5240
Practice Address - Country:US
Practice Address - Phone:541-265-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550111NP363LA2200X
OR200550112NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53489Medicare UPIN