Provider Demographics
NPI: | 1639509888 |
---|---|
Name: | TREMKO, MICHAEL P (PMHNP-BC) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | MICHAEL |
Middle Name: | P |
Last Name: | TREMKO |
Suffix: | |
Gender: | M |
Credentials: | PMHNP-BC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1101 CUMBERLAND XING # 279 |
Mailing Address - Street 2: | |
Mailing Address - City: | VALPARAISO |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46383-2356 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-364-6093 |
Mailing Address - Fax: | 503-212-0209 |
Practice Address - Street 1: | 2250 D ST NE |
Practice Address - Street 2: | |
Practice Address - City: | SALEM |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97301 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-364-6093 |
Practice Address - Fax: | 503-364-5121 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2013-11-24 |
Last Update Date: | 2024-03-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 200842665RN | 163WP0808X |
IN | 71012936A | 363LP0808X |
WA | AP61252566 | 363LP0808X |
ID | 69022 | 363LP0808X |
OR | 201502375NP-PP | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 163WP0808X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health |