Provider Demographics
NPI:1891756656
Name:KIRKWOOD, MYRON DEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:DEAN
Last Name:KIRKWOOD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14525 SW MILLIKAN WAY # 9658
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2343
Mailing Address - Country:US
Mailing Address - Phone:503-507-3117
Mailing Address - Fax:866-336-9931
Practice Address - Street 1:14525 SW MILLIKAN WAY # 9658
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2343
Practice Address - Country:US
Practice Address - Phone:503-507-3117
Practice Address - Fax:866-336-9931
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR091006974367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100212Medicaid
OR840229000OtherREGENCE BCBSO
OR118212Medicare ID - Type Unspecified
OR840229000OtherREGENCE BCBSO
S01997Medicare UPIN
OR100212Medicaid