Provider Demographics
NPI:1376374561
Name:PIDGEON, MICHAEL (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PIDGEON
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 1:2260 N SUMMIT AVE APT 312
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704301083163W00000X
WI260865-30163W00000X
OR10027219163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse