Provider Demographics
NPI:1881188084
Name:GERIATRIC PSYCHIATRY ASSOCIATES
Entity Type:Organization
Organization Name:GERIATRIC PSYCHIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:503-212-4243
Mailing Address - Street 1:17815 SW CHAPARRAL DR
Mailing Address - Street 2:
Mailing Address - City:POWELL BUTTE
Mailing Address - State:OR
Mailing Address - Zip Code:97753-0456
Mailing Address - Country:US
Mailing Address - Phone:503-212-4243
Mailing Address - Fax:833-218-3122
Practice Address - Street 1:123 NW 12TH AVE APT 424
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-4145
Practice Address - Country:US
Practice Address - Phone:503-367-3572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1717022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty