Provider Demographics
NPI:1689966806
Name:HARSONO, MICHELLE MEILANIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MEILANIE
Last Name:HARSONO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:SUITE 420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-288-7303
Practice Address - Fax:503-288-3806
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA155408363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641881Medicaid
ORP01501040Medicare PIN
OR180745Medicare PIN