Provider Demographics
NPI:1922001536
Name:MYKLEBUST, ERIN K (ANP)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:K
Last Name:MYKLEBUST
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:STE 261
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6601
Practice Address - Country:US
Practice Address - Phone:503-216-6300
Practice Address - Fax:503-216-6324
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR092007010N3363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236475Medicaid
OR236475Medicaid
PO8496Medicare UPIN
OR236475Medicaid