Provider Demographics
NPI: | 1811011174 |
---|---|
Name: | AVILA, PAMELA T (PNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | PAMELA |
Middle Name: | T |
Last Name: | AVILA |
Suffix: | |
Gender: | F |
Credentials: | PNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2800 N VANCOUVER AVE |
Mailing Address - Street 2: | SUITE 201 |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97227-1630 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-331-2400 |
Mailing Address - Fax: | 503-331-2410 |
Practice Address - Street 1: | 2800 N VANCOUVER AVE |
Practice Address - Street 2: | SUITE 201 |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97227-1630 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-331-2400 |
Practice Address - Fax: | 503-331-2410 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-03-19 |
Last Update Date: | 2011-03-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 088006229N1 | 363LF0000X, 363LP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 211086 | Medicaid |