Provider Demographics
NPI:1992014195
Name:POGGIALI, LAURA BEHRENDS (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BEHRENDS
Last Name:POGGIALI
Suffix:
Gender:F
Credentials:PA
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:
Mailing Address - Fax:
Practice Address - Street 1:16180 SE SUNNYSIDE RD
Practice Address - Street 2:STE 102
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015-6301
Practice Address - Country:US
Practice Address - Phone:503-582-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60188653363A00000X
ORPA170977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500682750Medicaid
ORP01522452OtherRR MEDICARE (PH&S)
ORP01522452OtherRR MEDICARE (PH&S)