Provider Demographics
NPI:1710674916
Name:POLAMALU GORDON, MEGAN A (CHW)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:POLAMALU GORDON
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:A
Other - Last Name:POLAMALU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8645 SE SUNNYBROOK BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6841
Mailing Address - Country:US
Mailing Address - Phone:503-659-1694
Mailing Address - Fax:503-659-8984
Practice Address - Street 1:8645 SE SUNNYBROOK BLVD # 200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6841
Practice Address - Country:US
Practice Address - Phone:503-659-1694
Practice Address - Fax:503-659-8984
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108611172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker