Provider Demographics
NPI:1790182392
Name:NOALL, TERRYOL BRANDON (DO)
Entity Type:Individual
Prefix:
First Name:TERRYOL
Middle Name:BRANDON
Last Name:NOALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MULLINS DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3983
Mailing Address - Country:US
Mailing Address - Phone:541-220-0139
Mailing Address - Fax:
Practice Address - Street 1:12518 NE AIRPORT WAY STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1090
Practice Address - Country:US
Practice Address - Phone:503-256-2992
Practice Address - Fax:503-258-0717
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15368208D00000X
ORDO202311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice