Provider Demographics
NPI:1740616770
Name:POWELL, LAURA BETHANY (AGACNP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:BETHANY
Last Name:POWELL
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:BETHANY
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAIL CODE SJH-2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-4910
Mailing Address - Fax:503-494-8368
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:MAIL CODE SJH-2
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-4910
Practice Address - Fax:503-494-8368
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC232481363LC0200X
NC5006497363LC0200X
OR201406086NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2550Medicaid
NC1740616770Medicaid
NCNCF349BMedicare PIN
NCNCF349AMedicare PIN