Provider Demographics
NPI:1629002639
Name:DUNLAP, MARY ANN (ANP)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:DUNLAP
Suffix:
Gender:F
Credentials:ANP
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:503-215-6644
Practice Address - Street 1:12442 SW SCHOLLS FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-0803
Practice Address - Country:US
Practice Address - Phone:503-215-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR94000300N3163W00000X
OR0094000300N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291754Medicaid
ORP00940157OtherRR MEDICARE
ORP00940157OtherRR MEDICARE
ORR130097Medicare PIN
P01680Medicare UPIN
ORR158870Medicare PIN
ORR149514Medicare PIN
ORR158869Medicare PIN