Provider Demographics
NPI:1891780524
Name:MIRLY, ALAN K (PA)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:K
Last Name:MIRLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:2525 NE 139TH ST STE 220
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1616
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2019-12-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-558363A00000X
WAPA60997082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2143194Medicaid
ID807225300Medicaid
IDPAWV4OtherBLUE CROSS