Provider Demographics
NPI:1649574443
Name:BOEH, MIRANDA SHEA (NP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:SHEA
Last Name:BOEH
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: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:
Mailing Address - Fax:
Practice Address - Street 1:17979 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6507
Practice Address - Country:US
Practice Address - Phone:503-962-1791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20366363LF0000X
OR201600700NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500707893Medicaid
ORR188382Medicare PIN
ORR188381Medicare PIN