Provider Demographics
NPI:1760487037
Name:MORGAN, LAVENA (MD)
Entity Type:Individual
Prefix:
First Name:LAVENA
Middle Name:
Last Name:MORGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6535 SE 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-8205
Mailing Address - Country:US
Mailing Address - Phone:503-983-5413
Mailing Address - Fax:
Practice Address - Street 1:6535 SE 34TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-8205
Practice Address - Country:US
Practice Address - Phone:503-983-5413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61090693207V00000X
ORMD21448207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151319Medicaid
ORR141736OtherMEMBER'S PROVIDER TRANSACTION ACCESS NUMBER (PTAN)
OR107569Medicare PIN
ORR141736OtherMEMBER'S PROVIDER TRANSACTION ACCESS NUMBER (PTAN)